What is the recommended approach for medical preoperative clearance?

Recommended Approach for Medical Preoperative Clearance

Medical preoperative clearance should be based on the patient's clinical history, comorbidities, and physical examination findings rather than routine testing for all patients, with targeted testing performed only when results would change perioperative management. 1, 2

Comprehensive Preoperative Assessment

• The purpose of preoperative evaluation is not to give "medical clearance" but to assess current medical status, make recommendations for perioperative management, and provide a clinical risk profile 1
• A thorough review of pertinent medical records, physical examination, and patient interview should be performed to identify conditions that may increase perioperative risk 1
• Verification of patient compliance with fasting requirements should be assessed at the time of the procedure 1

Cardiovascular Assessment

• ECG is recommended for patients with at least one clinical risk factor (coronary artery disease, heart failure, cerebrovascular disease, diabetes mellitus, renal insufficiency) who are undergoing vascular surgical procedures 1, 2
• ECG is recommended for patients with known coronary heart disease, peripheral arterial disease, or cerebrovascular disease undergoing intermediate-risk surgical procedures 1, 2
• Evaluation of left ventricular function is reasonable for patients with dyspnea of unknown origin or heart failure with worsening symptoms 1
• 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 patients 1, 2
• Chest radiography is reasonable for patients at risk of postoperative pulmonary complications if results would change perioperative management 1, 2
• Chest radiography is indicated for patients with new or unstable cardiopulmonary signs or symptoms 2

Laboratory Testing

Complete Blood Count

• CBC is indicated for patients with diseases that increase risk of anemia or when significant perioperative blood loss is anticipated 1, 2
• CBC is recommended for patients with history of anemia, recent blood loss, or hematologic disorders 2

Electrolytes and Renal Function

• Electrolyte and creatinine testing should be reserved for patients at risk of electrolyte abnormalities or renal impairment 1, 2
• Testing is recommended for patients taking medications that affect electrolytes or renal function (diuretics, ACE inhibitors, ARBs, NSAIDs) 2
• Patients with hypertension, heart failure, chronic kidney disease, diabetes mellitus, or liver disease should have electrolyte and creatinine testing 2

Glucose Testing

• Random glucose testing is recommended for patients at high risk of undiagnosed diabetes mellitus 1, 2
• In patients with diagnosed diabetes, A1C testing is recommended only if results would change perioperative management 1, 2

Coagulation Studies

• Coagulation testing should be reserved for patients with history of bleeding, medical conditions predisposing to coagulopathy (e.g., liver disease), or those taking anticoagulants 1, 2
• 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, 2
• Urinalysis is indicated for patients undergoing urologic procedures or implantation of foreign material (e.g., prosthetic joint, heart valve) 1, 2

Fasting Guidelines

• For healthy adults undergoing elective procedures, fasting from the intake of clear liquids for 2-4 hours before anesthesia is recommended 1
• Fasting from breast milk is recommended for at least 4 hours before elective procedures requiring anesthesia 1
• Verification of patient compliance with fasting requirements should be assessed at the time of the procedure 1

Special Considerations

• Patients in their usual state of health undergoing cataract surgery do not require preoperative testing 1
• The consultant should avoid phrases such as "cleared for surgery" and instead provide a comprehensive evaluation of the patient's risk 1
• No test should be performed unless it is likely to influence patient treatment 1

Common Pitfalls to Avoid

• Ordering routine "battery" tests for all patients regardless of clinical indication 1, 4
• Failing to communicate findings and recommendations clearly to the surgeon, anesthesiologist, and patient 1
• Using vague terminology like "cleared for surgery" instead of providing specific risk assessment and recommendations 1
• Overlooking the opportunity to address long-term cardiovascular risk reduction during preoperative evaluation 1