Essential Components for Surgical Clearance
A comprehensive surgical clearance template should include a detailed cardiac risk assessment, medical history, physical examination, and functional capacity evaluation to ensure optimal patient outcomes in terms of morbidity and mortality.
Cardiac Risk Assessment
History Components
- Identify serious cardiac conditions 1:
- Unstable coronary syndromes (unstable/severe angina, recent MI)
- Decompensated heart failure (NYHA class IV, worsening or new-onset HF)
- Significant arrhythmias (high-grade AV blocks, symptomatic arrhythmias)
- Severe valvular disease (severe aortic stenosis, symptomatic mitral stenosis)
- Document prior history of pacemaker or implantable cardioverter defibrillator 1
- Record modifiable risk factors for coronary heart disease 1
- Document associated diseases 1:
- Peripheral vascular disease
- Cerebrovascular disease
- Diabetes mellitus
- Renal impairment
- Chronic pulmonary disease
Medication Review
- Accurate documentation of current medications with dosages 1
- Include herbal and nutritional supplements 1
- Document use of alcohol, tobacco, over-the-counter and illicit drugs 1
Functional Capacity Assessment
- Evaluate ability to perform daily tasks (correlates with maximum oxygen uptake) 1
- Document in metabolic equivalents (METs) 1:
- 1 MET: Basic self-care activities
- 4 METs: Climbing stairs, walking on level ground at 4 mph
10 METs: Participation in strenuous sports
Physical Examination
- Comprehensive cardiovascular examination 1
- Vital signs assessment (particularly cardiovascular) 1
- Volume status evaluation 1
- Chest examination 1
Laboratory and Diagnostic Testing
- Essential tests based on patient's condition and surgical risk 1, 2:
- Hematocrit
- Electrolytes
- Renal function tests
- Urinalysis
- ECG (particularly in patients ≥50 years old) 1
- Additional testing only if results would change management 1, 2
Special Considerations
COVID-19 Screening (When Applicable)
- Body temperature measurement 1
- COVID-19 testing as per institutional protocol 1
- Chest examination and review of chest imaging 1
Allergy Assessment
- Document history of drug allergies 3, 4
- Use structured questionnaire to accurately identify true allergies versus side effects 3
- Document allergies to anesthetic agents, antibiotics, latex, and other perioperative medications 5
Risk Stratification and Recommendations
- Clear documentation of cardiac risk category 1
- Specific recommendations for perioperative management 1:
- Medication adjustments
- Additional testing if indicated
- Level of postoperative care needed
- Avoid phrases like "clear for surgery" 1
Communication Plan
- Direct communication with surgeon, anesthesiologist, and other physicians 1
- Discussion with patient and family about risks 1
- Documentation of findings and recommendations in medical record 1
Common Pitfalls to Avoid
- Ordering unnecessary tests that won't change management 1, 2
- Using vague terminology like "cleared for surgery" 1
- Failing to communicate directly with the surgical team 1
- Overlooking functional capacity assessment, which is a strong predictor of outcomes 1
- Incomplete medication reconciliation, especially regarding anticoagulants 6
- Misclassifying drug allergies without proper verification 3, 4
Remember that the preoperative evaluation may represent the first careful cardiovascular assessment for some patients, making it an opportunity to address long-term health issues beyond the immediate surgical needs 1.