What are the recommended procedures for pre-operative (pre-op) screening?

Recommended Procedures for Pre-Operative Screening

Preoperative testing should be based on the patient's clinical history, comorbidities, physical examination findings, and perioperative risk assessment rather than performed routinely for all patients. 1

Cardiovascular Assessment

• Electrocardiography (ECG) is recommended for patients with signs or symptoms of cardiovascular disease 1
• ECG is indicated for patients undergoing high-risk surgery and those undergoing intermediate-risk surgery who have additional risk factors (coronary heart disease, structural heart disease, heart failure, cerebrovascular disease, diabetes, or renal impairment) 2
• Patients undergoing low-risk surgery do not require ECG 1
• Risk stratification should identify active cardiac conditions requiring evaluation before surgery (unstable coronary syndromes, decompensated heart failure, significant arrhythmias, severe valvular disease) 2
• Patients with good functional capacity (≥4 METs or ability to climb ≥2 flights of stairs) can generally proceed to surgery without further cardiac testing 2, 3

Pulmonary Assessment

• Chest radiography is not recommended routinely for asymptomatic, otherwise healthy patients 1
• Chest radiography is indicated for patients with new or unstable cardiopulmonary signs or symptoms 1
• Consider chest radiography for patients at risk of postoperative pulmonary complications if results would change perioperative management 1

Laboratory Testing

Complete Blood Count (CBC)

• CBC is indicated for patients with diseases that increase risk of anemia (liver disease, hematologic disorders) 1
• CBC is recommended for patients with history of anemia or recent blood loss 1
• CBC should be performed when significant perioperative blood loss is anticipated 1
• CBC is indicated for patients undergoing cardiovascular surgery and specific high-risk procedures 1

Electrolytes and Renal Function

• Electrolyte and creatinine testing should be reserved for patients at risk of electrolyte abnormalities or renal impairment 1
• Testing is recommended for patients taking medications that predispose to electrolyte abnormalities (diuretics, ACE inhibitors, ARBs, NSAIDs, digoxin) 1
• Patients with hypertension, heart failure, chronic kidney disease, complicated diabetes mellitus, or liver disease should have electrolyte and creatinine testing 1
• Electrolyte measurement is recommended for all patients with known renal conditions and those undergoing neurosurgery or cardiovascular surgery 1

Glucose and A1C Testing

• Random glucose testing should be performed in patients at high risk of undiagnosed diabetes mellitus 1
• In patients with diagnosed diabetes, A1C testing is recommended only if results would change perioperative management 1
• The incidence of occult diabetes in the presurgical population is low (0.5%), so universal screening is not justified 1

Coagulation Studies

• Coagulation testing (prothrombin time, activated partial thromboplastin time, platelet count) should be reserved for patients with history of bleeding or medical conditions predisposing to coagulopathy (e.g., liver disease) 1
• Testing is indicated for patients taking anticoagulants 1
• Indiscriminate preoperative coagulation testing is not warranted due to low prevalence of inherited coagulopathies 1

Urinalysis

• Routine urinalysis is not recommended for asymptomatic patients 1
• Urinalysis is indicated for patients undergoing urologic procedures or implantation of foreign material (e.g., prosthetic joint, heart valve) 1

Timing of Testing

• For relatively healthy patients (ASA physical status I-II), laboratory testing performed up to 2 months before surgery does not increase risk of 30-day morbidity and mortality, suggesting retesting shortly before surgery is unnecessary 4
• Testing performed 2-3 months before surgery may be associated with increased risk compared to testing within 2 months 4

Special Considerations

• Patients in their usual state of health undergoing cataract surgery do not require preoperative testing 1
• Older adults (≥75 years) and patients with coronary stents have higher risk of perioperative myocardial infarction and major adverse cardiovascular events, warranting careful preoperative consideration 3
• Routine perioperative use of high-dose β-blockers shortly before surgery is associated with higher risk of stroke and mortality and should not be routinely used 3

Cost Considerations

• Approximately $18 billion is spent annually on preoperative testing in the US, with significant potential for waste reduction 5
• Eliminating unnecessary testing reduces costs without compromising safety and quality of care 6