What are the recommendations for grade preoperative surgical clearance?

Preoperative Surgical Clearance Guidelines

Preoperative surgical clearance should be based primarily on patient-specific risk factors and the type of surgery planned, with selective testing guided by clinical findings rather than routine testing for all patients. 1

General Approach to Preoperative Assessment

Medical History and Physical Examination Focus

• Prioritize assessment of cardiovascular disease, pulmonary disease, renal disease, diabetes, bleeding disorders, and medication review 1
• Vital signs, cardiovascular system, respiratory system, and airway assessment are essential components 1

Risk Stratification

• Stratify patients based on:
  • Surgical risk (low, intermediate, high)
  • Patient comorbidities
  • Functional capacity

Laboratory Testing Recommendations

Complete Blood Count (CBC)

• Indicated for:
  • History of anemia or recent blood loss
  • Hematologic disorders
  • Anticipated significant blood loss
  • Cardiovascular surgery
  • Elderly patients undergoing major surgery 1
• Not indicated for healthy patients undergoing low-risk procedures

Electrolyte Testing

• Indicated for:
  • Patients taking diuretics, ACE inhibitors, or ARBs
  • Known renal disease
  • Patients undergoing major surgery 2, 1
• Not indicated for healthy patients undergoing low-risk procedures

Coagulation Testing

• Indicated only for:
  • Patients taking anticoagulants
  • History of bleeding disorders
  • Liver disease or other conditions predisposing to coagulopathy 1
• Not indicated as routine screening

Glucose Testing

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

Diagnostic Testing

Electrocardiogram (ECG)

• Recommended for:
  • Patients with known heart disease, peripheral vascular disease, or cerebrovascular disease undergoing intermediate or high-risk surgery
  • Patients with one or more clinical risk factors undergoing vascular surgery 2
  • Patients with active cardiovascular signs or symptoms 1
• Consider for:
  • Patients with one or more clinical risk factors undergoing intermediate-risk surgery
  • Patients with no clinical risk factors undergoing vascular surgery 2
• Not indicated for asymptomatic patients undergoing low-risk surgery 2

Chest X-ray

• Indicated for:
  • Patients with new or unstable cardiopulmonary signs or symptoms
  • Patients at risk of postoperative pulmonary complications if results would change management 1
• Not indicated for asymptomatic patients without cardiopulmonary disease or those undergoing low-risk surgery 1

Special Considerations

Preoperative Optimization

• Smoking cessation:

  • Should occur at least 4 weeks before surgery to reduce respiratory and wound-healing complications 2
  • Even shorter periods may yield benefits
  • Intense counseling and nicotine replacement therapy are most effective 2

• Alcohol cessation:

  • Recommended for 4 weeks before surgery in patients with alcohol abuse 2
  • Reduces postoperative infections but not mortality 2

Medication Management

• Dietary supplements:

  • Supplements that may affect bleeding risk (e.g., garlic, ginger, ginkgo) should be held for 2 weeks before surgery 2
  • Fish oil/omega-3 fatty acid preparations can be continued as prior concerns about bleeding risk have not been confirmed 2
  • Supplements that may cause CNS depression should be held for 2 weeks before surgery 2

• Beta blockers:

  • Should be administered for at least 24 hours before surgery to patients already on them to reduce postoperative atrial fibrillation 2
  • Should be reinstituted as soon as possible after surgery 2

Preoperative Fasting and Carbohydrate Loading

• Fasting of 2 hours for liquids and 6 hours for solids before anesthesia is safe 2
• Carbohydrate loading is recommended the evening before surgery and 2-4 hours before anesthesia 2

Common Pitfalls to Avoid

• Overreliance on routine testing leads to unnecessary delays and costs, as only 0.1-0.5% of routine preoperative tests result in changes to perioperative management 1
• Inadequate risk stratification can lead to inappropriate testing and preparation
• Medication management errors, particularly with anticoagulants and antiplatelets
• Failure to communicate findings between specialists involved in patient care

Multidisciplinary Approach

• A multidisciplinary team approach is recommended for patients with clinically significant comorbidities 2
• For patients with significant carotid artery disease, a team consisting of cardiologist, cardiac surgeon, vascular surgeon, and neurologist is recommended 2

By following these evidence-based guidelines for preoperative assessment, clinicians can ensure appropriate risk stratification and optimization while avoiding unnecessary testing, leading to improved patient outcomes and resource utilization.