Recommended Screening Tools for Surgical Clearance in Primary Care
Primary care providers should use a selective, risk-based approach to preoperative evaluation rather than routine testing for all surgical patients, focusing on medical record review, patient interview, directed physical examination, and targeted preoperative testing based on specific patient and surgical risk factors. 1
Patient Assessment Components
Medical History Review
- Review previous medical records within 6 months of surgery (if available and unchanged) 1
- Screen for:
- Previous anesthetic complications
- Cardiovascular problems (hypertension, coronary disease, heart failure)
- Respiratory conditions (COPD, asthma, sleep apnea)
- Diabetes and metabolic disorders
- Renal disease
- Bleeding disorders or anticoagulant use
- Substance use (alcohol, tobacco, illicit drugs)
Medication Review
- Document all current medications with dosages
- Assess herbal supplements and nutritional supplements 1
- Plan for perioperative medication management:
- Continue beta blockers in patients already taking them
- Hold anticoagulants based on procedure risk
- Discontinue supplements affecting bleeding risk 2 weeks before surgery 1
Functional Capacity Assessment
- Evaluate exercise tolerance (ability to climb two flights of stairs) 2
- Assess for barriers to communication and ability to cooperate 1
Physical Examination
- Vital signs including blood pressure in both arms
- Focused cardiopulmonary examination
- Airway assessment (especially for OSA risk)
- Neck circumference, tonsil size, and tongue volume 1
Risk Assessment Tools
1. Cardiac Risk Assessment
- Thoracic Revised Cardiac Risk Index (ThRCRI) for lung resection candidates 2
- More specific than traditional RCRI for thoracic surgery
- Patients with ThRCRI > 1.5 should be referred for cardiac consultation
2. Pulmonary Risk Assessment
- For patients with lung cancer being considered for resection:
- Cardiopulmonary fitness evaluation regardless of age 2
- Consider tumor stage, patient life expectancy, and performance status
3. COVID-19 Screening
- In areas with high COVID-19 prevalence:
- RT-PCR testing 72-96 hours before elective procedures 2
- Rapid testing for emergent procedures
- Consider chest imaging for symptomatic patients
Selective Preoperative Testing
| Test | Indication |
|---|---|
| Renal function | Patients on diuretics, ACE inhibitors, ARBs; known renal disease; major surgery [1] |
| Electrolytes | Patients on diuretics, ACE inhibitors, ARBs; known renal disease; major surgery [1] |
| Coagulation | Patients on anticoagulants; history of bleeding disorders; liver disease [1] |
| Random glucose | Patients at high risk of undiagnosed diabetes [1] |
| HbA1C | Diabetic patients only if results would change management [1] |
| CBC | History of anemia; anticipated significant blood loss; cardiovascular surgery; elderly patients undergoing major surgery [1] |
| ECG | Active cardiovascular symptoms; known cardiovascular disease undergoing intermediate/high-risk surgery; multiple risk factors undergoing vascular surgery [1] |
| Chest X-ray | New/unstable cardiopulmonary symptoms; patients at risk of postoperative pulmonary complications [1] |
Preoperative Optimization
Smoking Cessation
- Recommend cessation at least 4 weeks before surgery to reduce respiratory and wound-healing complications 2
Alcohol Cessation
- Recommend abstinence for 4 weeks prior to surgery for patients with alcohol abuse 2
Nutritional Optimization
- Screen for malnutrition
- Consider carbohydrate loading the evening before surgery and 2-4 hours before anesthesia 2, 1
Fasting Guidelines
Important Considerations
Primary Care Follow-up
Recent evidence shows that established primary care use is associated with 19-27% lower odds of postoperative mortality following emergency general surgery, highlighting the importance of primary care involvement in surgical patients 3.
Avoiding Unnecessary Testing
Research shows that standardized preoperative screening programs with routine testing for all patients do not significantly reduce surgical cancellation rates compared to selective testing based on history and physical examination 4. Only 1% of standardized preadmission screens lead to surgery cancellation, suggesting that targeted testing is more efficient.
Special Populations
For elderly patients, a thorough assessment is particularly important due to comorbidities, polypharmacy, functional problems, and socioeconomic issues that can affect perioperative decisions 5.
By following this structured approach to preoperative evaluation, primary care providers can effectively identify surgical risks while avoiding unnecessary testing, ultimately improving patient outcomes and resource utilization.