From the Guidelines
A pre-operative assessment from an internal medicine perspective involves a comprehensive evaluation of a patient's medical status to identify and mitigate risks before surgery, with the goal of promoting patient engagement and facilitating shared decision making by providing patients and their providers with clear, understandable information about perioperative cardiovascular risk in the context of the overall risk of surgery 1. This assessment typically includes a thorough review of the patient's medical history, current medications, allergies, and previous surgical experiences.
Key Components of Pre-Operative Assessment
- Physical examination focusing on cardiovascular and pulmonary systems, with vital signs measurement and assessment of functional capacity
- Laboratory testing, including complete blood count, basic metabolic panel, coagulation studies, and electrocardiogram, with additional tests like chest X-rays or echocardiograms ordered based on specific risk factors
- Medication management, with decisions about continuing or temporarily stopping medications like anticoagulants, antihypertensives, and diabetes medications, as recommended by the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 2 ### Medication Management For instance, warfarin is typically stopped 5 days before surgery, while most antihypertensives are continued except ACE inhibitors which may be held the morning of surgery. The internist also evaluates and optimizes chronic conditions such as diabetes (aiming for glucose levels below 180 mg/dL), hypertension, and cardiac issues. This comprehensive approach helps reduce perioperative complications by identifying high-risk patients, optimizing medical conditions, and ensuring appropriate perioperative management plans are in place, as emphasized by the 2014 ACC/AHA guideline 1.
Importance of Communication and Shared Decision Making
The key to optimal management is communication among all of the relevant parties (ie, surgeon, anesthesiologist, primary caregiver, and consultants) and the patient, as highlighted in the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 2. This communication facilitates shared decision making and promotes patient engagement, ultimately leading to better outcomes and reduced morbidity and mortality. By prioritizing a comprehensive pre-operative assessment and effective communication, healthcare providers can ensure that patients receive optimal care and minimize the risks associated with surgery 1, 2.
From the FDA Drug Label
TREATMENT DURING DENTISTRY AND SURGERY The management of patients who undergo dental and surgical procedures requires close liaison between attending physicians, surgeons and dentists. PT/INR determination is recommended just prior to any dental or surgical procedure.
From an internal medicine perspective, a pre-operative (pre-op) assessment includes:
- PT/INR determination just prior to any surgical procedure
- Close liaison between attending physicians, surgeons, and dentists to manage patients undergoing dental and surgical procedures 3
From the Research
Pre-Operative Assessment Components
- A history and physical examination are essential components of preoperative evaluation, focusing on risk factors for cardiac and pulmonary complications and determining the patient's functional capacity 4
- Evaluation of the patient's medical history and physical examination are the cornerstones of risk assessment prior to elective surgery, and may help to optimize the patient's preoperative medical condition and guide perioperative management 5, 6
- 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 4
Risk Assessment and Management
- The preoperative assessment involves procedures that are implemented based on the nature of the expected operation as well as the findings of the diagnostic workup and the preoperative evaluation 4
- The performance of additional technical tests, such as blood chemistry, electrocardiography, spirometry, and chest x-ray, may contribute to the reduction of perioperative risk, but their use is often not well known or is controversial 5, 6
- The perioperative management of the patient's long-term medication is an important aspect of preoperative evaluation, and there is considerable uncertainty among anesthesiologists, internists, and surgeons with respect to this topic 5, 6
Educational Resources and Guidelines
- Preoperative assessment is a core competency for internal medicine residents, and educational resources on this topic are limited 7
- Joint recommendations from the German Scientific Societies of Anesthesiology and Intensive Care Medicine, Internal Medicine, and Surgery provide a common basis for structured preoperative risk assessment and management 5, 6
- These recommendations aim to ensure that surgical patients undergo a rational preoperative assessment and avoid unnecessary, costly, and potentially dangerous testing 5, 6
Importance of History and Physical Examination
- A thorough history taking and physical examination of all patients before surgery seems important, although the amount of detail required to obtain a reasonable estimate of perioperative risk remains unclear 8
- The benefits of routine testing for all surgical patients before operation are extremely limited and are not advocated 8