What is the recommended preoperative assessment and planning for patients undergoing surgery?

Comprehensive Preoperative Assessment and Planning

The most effective preoperative assessment should be based on the patient's clinical history, physical examination findings, perioperative risk assessment, and clinical judgment rather than routine testing for all patients. 1

Risk-Based Approach to Preoperative Testing

Initial Assessment

• Complete medical history focusing on:

  • Cardiovascular disease (history of CAD, heart failure, arrhythmias)
  • Pulmonary disease (COPD, asthma, sleep apnea)
  • Renal disease
  • Diabetes and other endocrine disorders
  • Bleeding disorders or anticoagulant use
  • Previous surgical and anesthetic complications
  • Current medications and allergies
  • Functional capacity (ability to climb stairs, perform daily activities)

• Physical examination with emphasis on:

  • Vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation)
  • Cardiovascular system (murmurs, irregular rhythms, signs of heart failure)
  • Respiratory system (wheezing, crackles, decreased breath sounds)
  • Airway assessment (Mallampati score, neck mobility, dentition)

Laboratory Testing

Complete Blood Count (CBC)

CBC is indicated for:

• Patients with history of anemia or recent blood loss 1
• Patients with hematologic disorders 1
• Patients undergoing procedures with anticipated significant blood loss 1
• Patients undergoing cardiovascular surgery 1
• Elderly patients (>60 years) undergoing major surgery 1

Electrolytes and Renal Function

Indicated for:

• Patients taking diuretics, ACE inhibitors, or ARBs 1
• Patients with known renal disease 1
• Patients undergoing major surgery (grade 3-4) 1
• Patients with cardiovascular disease 1
• Patients >60 years with comorbidities undergoing intermediate or high-risk surgery 1

Coagulation Studies

Indicated only for:

• Patients taking anticoagulants 1
• Patients with history of bleeding disorders 1
• Patients with liver disease or other conditions predisposing to coagulopathy 1

Blood Glucose/HbA1C

• Random glucose testing for patients at high risk of undiagnosed diabetes 1
• HbA1C testing in diabetic patients only if results would change perioperative management 1

Cardiovascular Assessment

Electrocardiography (ECG)

ECG is recommended for:

• Patients with active cardiovascular signs or symptoms 1, 2
• Patients with known cardiovascular disease undergoing intermediate or high-risk surgery 2
• Patients with multiple risk factors (diabetes, renal insufficiency, cerebrovascular disease) undergoing vascular surgery 2

ECG is not indicated for:

• Asymptomatic patients undergoing low-risk surgery 2
• Young, healthy patients without cardiovascular risk factors 2

Advanced Cardiac Testing

Consider stress testing or cardiology consultation for:

• Patients with poor functional capacity (<4 METs) and multiple risk factors undergoing high-risk surgery
• Patients with unstable cardiac conditions

Pulmonary Assessment

Chest Radiography

Chest X-ray is indicated for:

• Patients with new or unstable cardiopulmonary signs or symptoms 1, 2
• Patients at risk of postoperative pulmonary complications if results would change management 2

Chest X-ray is not indicated for:

• Asymptomatic patients without cardiopulmonary disease 2
• Patients undergoing low-risk surgery 2
• Young patients without risk factors 2

Special Populations

Patients with Congenital Heart Disease

• Basic preoperative assessment should include systemic arterial oximetry, ECG, chest X-ray, TTE, and blood tests for full blood count and coagulation 1
• High-risk patients (prior Fontan procedure, severe PAH, cyanotic CHD, complex CHD with residua) should be managed at specialized centers 1
• Consultation with ACHD experts is recommended for risk assessment 1
• Consultation with a cardiac anesthesiologist is recommended for moderate and high-risk patients 1

Patients with Sickle Cell Disease

• Multidisciplinary collaboration between surgeon, anesthesiologist, hematologist, and blood bank specialist is mandatory 1
• Preoperative transfusion decisions should be made on a case-by-case basis 1
• For minor and intermediate risk surgery, preoperative transfusion is associated with decreased perioperative complications 1

Patients Undergoing Cataract Surgery

• Patients in their usual state of health undergoing cataract surgery do not require preoperative testing 1
• Routine preoperative laboratory testing has not been shown to reduce perioperative morbidity and mortality in cataract surgery 1

Thromboembolism Prophylaxis

• Low-dose heparin prophylaxis (5,000 units 2 hours before surgery and every 8-12 hours thereafter) should be considered for patients over 40 undergoing major surgery 3
• Continue prophylaxis for 7 days or until fully ambulatory 3
• Exclude patients with bleeding disorders and those having neurosurgery, spinal anesthesia, eye surgery, or potentially sanguineous operations 3
• Screen all patients prior to heparinization to rule out bleeding disorders 3

Common Pitfalls to Avoid

1. Overreliance on routine testing: Only 0.1-0.5% of routine preoperative tests result in changes to perioperative management 2

2. Inadequate risk stratification: Failure to properly assess cardiac risk can lead to unnecessary testing or inadequate preparation

3. Medication management errors: Failure to appropriately continue or discontinue chronic medications perioperatively

4. Delayed surgical intervention: Unnecessary testing can delay surgery and increase costs without improving outcomes

5. Neglecting functional capacity assessment: A patient's ability to perform daily activities provides valuable information about their physiological reserve

6. Failure to communicate findings: Ensure all abnormal findings are communicated to the surgical and anesthesia teams

By following this evidence-based approach to preoperative assessment, clinicians can optimize patient outcomes while avoiding unnecessary testing and delays in care.