What is the recommended preoperative evaluation and management for asymptomatic patients undergoing surgery?

From the Guidelines

The recommended preoperative evaluation for asymptomatic patients undergoing surgery should be tailored to the individual's risk factors, comorbidities, and the planned procedure, with a focus on minimizing unnecessary testing and promoting patient engagement in shared decision making 1.

Key Considerations

• For healthy patients undergoing low-risk procedures, minimal testing is needed beyond a focused history and physical examination.
• Laboratory tests should be ordered selectively based on specific indications rather than routinely.
• Cardiac evaluation, including ECG, is recommended for patients over 65 years, those with cardiovascular disease, or when undergoing intermediate to high-risk procedures, as stated in the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1.

Preoperative Testing

• Routine preoperative resting 12-lead ECG is not useful for asymptomatic patients undergoing low-risk surgical procedures (Class III: No Benefit, Level of Evidence: B) 1.
• Preoperative resting 12-lead ECG may be considered for asymptomatic patients, except for low-risk surgery (Class IIb, Level of Evidence: B) 1.
• Exercise stress testing may be considered for patients with elevated risk and unknown functional capacity, but routine screening with noninvasive stress testing is not useful for low-risk noncardiac surgery (Class III: No Benefit, Level of Evidence: B) 1.

Medication Management

• Most chronic medications should be continued perioperatively, particularly antihypertensives, beta-blockers, and statins.
• Certain medications like anticoagulants, insulin, and oral hypoglycemics may require adjustment.
• ACE inhibitors and ARBs are typically held on the day of surgery to prevent intraoperative hypotension.

Communication and Shared Decision Making

• The key to optimal management is communication among all relevant parties (i.e., surgeon, anesthesiologist, primary caregiver, and consultants) and the patient.
• The goal of preoperative evaluation is to promote patient engagement and facilitate 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.

From the FDA Drug Label

Chronically administered beta-blocking therapy should not be routinely withdrawn prior to major surgery; however, the impaired ability of the heart to respond to reflex adrenergic stimuli may augment the risks of general anesthesia and surgical procedures 2 Major Surgery Chronically administered beta-blocking therapy should not be routinely withdrawn prior to major surgery, however, the impaired ability of the heart to respond to reflex adrenergic stimuli may augment the risks of general anesthesia and surgical procedures 3

Preoperative Evaluation and Management for Asymptomatic Patients:

• Chronically administered beta-blocking therapy should not be routinely withdrawn prior to major surgery.
• The impaired ability of the heart to respond to reflex adrenergic stimuli may augment the risks of general anesthesia and surgical procedures.
• No routine withdrawal of beta-blocking therapy is recommended for asymptomatic patients undergoing surgery.
• Patients should be carefully monitored and managed according to current guidelines.

From the Research

Preoperative Evaluation for Asymptomatic Patients

The preoperative evaluation for asymptomatic patients undergoing surgery should be driven by the patient's history and physical examination and the risk of the surgical procedure 4.

• The evaluation should focus on identifying potential risks and optimizing the patient's health before surgery.
• A thorough clinical examination supported by appropriate laboratory tests is essential to guide the clinician in providing optimal perioperative care 5.
• Patient comorbidities and risk factors are important to the success of any operation, and knowing about them before surgery can help clinicians anticipate perioperative complications and optimize patient conditions 6.

Key Considerations

• Preoperative laboratory and electrocardiographic testing should only be performed if it can correctly identify abnormalities and will change the diagnosis, the management plan, or the patient's outcome 4.
• A clear and comprehensive system should be in place to process patients during the preoperative period, taking into account specific and unique personnel and system requirements for the accumulation of multidisciplinary information 7.
• Preoperative evaluation centers can help hospitals standardize and optimize preoperative testing while fostering more consistent regulatory documentation and appropriate coding for reimbursement 4.

Risk Stratification

• Risk stratification for common conditions, such as pulmonary risk, is crucial in the preoperative assessment of patients undergoing elective noncardiac surgery 6, 5.
• A thorough evaluation of patients with neurological diseases undergoing surgery can reduce perioperative morbidity and mortality, especially stroke 8.