What is the optimal preoperative management for patients with co-morbidities (co-existing medical conditions) undergoing surgery?

Optimal Preoperative Management for Patients with Co-morbidities

The optimal preoperative management for patients with co-morbidities requires a structured risk assessment followed by targeted optimization of specific medical conditions to reduce perioperative morbidity and mortality. 1

Risk Assessment Framework

• Evaluate cardiac risk using the revised Lee cardiac risk index based on high-risk surgery, ischemic heart disease, heart failure, cerebrovascular disease, insulin-dependent diabetes, renal dysfunction, and age >75 1
• For urgent/emergency surgery, proceed with limited evaluation focusing on vital signs, volume status, hematocrit, electrolytes, renal function, and ECG 2
• Screen for unstable coronary syndromes, decompensated heart failure, significant arrhythmias, and severe valvular disease, and consider delaying surgery for cardiac stabilization if present 2
• Low-risk procedures (<1% cardiac risk) can proceed with appropriate medical therapy, while higher-risk procedures require more extensive evaluation 2

Cardiovascular Optimization

• Beta blockers should be continued in patients already receiving them for angina, symptomatic arrhythmias, or hypertension 2
• For patients undergoing vascular surgery with clinical risk factors, beta blockers may be beneficial when started between 30 days and at least 2 days before surgery 1
• For patients undergoing vascular surgery, statin use is reasonable regardless of risk factors 2
• A 12-lead ECG is recommended for patients with at least one clinical risk factor undergoing vascular surgical procedures 1
• Left ventricular function assessment is reasonable for patients with dyspnea of unknown origin or current/prior heart failure with worsening symptoms 1

Pulmonary Optimization

• Smoking cessation should be implemented at least 4 weeks before surgery to reduce respiratory and wound-healing complications 1
• For patients with obstructive sleep apnea, screening with tools like STOP-BANG can identify high-risk patients who may need further evaluation with polysomnography 3
• Patients with severe obesity have increased risk of cardiopulmonary complications and may require additional respiratory assessment 2, 3

Metabolic and Nutritional Optimization

• Hemoglobin A1c should be measured preoperatively for risk stratification, aiming for levels <7% to reduce complications 1
• Assess serum albumin levels preoperatively as hypoalbuminemia correlates with increased ventilator time, acute kidney injury, infection, longer hospital stays, and mortality 1
• Preoperative abstinence from alcohol for 4 weeks is strongly recommended for patients consuming more than two units of alcohol per day 1

Medication Management

• For patients on antiplatelet therapy like clopidogrel, discontinuation increases the risk of cardiovascular events, but may be necessary to reduce bleeding risk during surgery 4
• When possible, interrupt clopidogrel therapy for five days prior to surgery with major bleeding risk and resume as soon as hemostasis is achieved 4
• For patients with heart failure and systolic LV dysfunction (LVEF <40%), ACEIs or ARBs should be considered before surgery 1
• Restart ACE inhibitors only after confirming the patient is euvolemic to decrease risk of perioperative renal dysfunction 1

Intraoperative Considerations

• Volatile anesthetic agents can be beneficial during noncardiac surgery for maintenance of general anesthesia in hemodynamically stable patients at risk for myocardial ischemia 2
• Maintenance of body temperature in a normothermic range is recommended for most procedures 2
• Blood glucose concentration should be controlled during the perioperative period in patients with diabetes mellitus or acute hyperglycemia who are at high risk for myocardial ischemia 2
• Careful management of fluid shifts is essential, especially in patients with heart failure or cardiomyopathy 1

Special Populations

Elderly Patients

• Age alone is responsible for only a small increase in risk; greater risks are associated with urgency and significant cardiac, pulmonary, and renal disease 2
• The elderly population will increase by >50% within 20 years, and these patients require surgery four times more often than the rest of the population 2

Severely Obese Patients

• Severe obesity is associated with comorbidities that may lead to disability and death 2
• Possible cardiac symptoms such as exertional dyspnea and lower-extremity edema occur commonly and are nonspecific in obesity 2
• The physical examination and electrocardiogram often underestimate cardiac dysfunction in obese patients 2

Common Pitfalls to Avoid

• Viewing preoperative evaluation as simply "giving medical clearance" rather than a comprehensive risk assessment 1
• Performing tests that will not influence perioperative management 1
• Failing to communicate findings and recommendations to all members of the perioperative team 1
• Delaying urgent surgery unnecessarily for extensive testing when limited evaluation would suffice 2

Multidisciplinary Approach

• Effective communication among surgeon, anesthesiologist, primary physician, and consultants is essential 1
• Treatment options for patients with active cardiac conditions should be discussed in a multidisciplinary team 1
• Pre-assessment should be undertaken by both a senior geriatrician and a senior anaesthetist with specific subspecialty training in geriatrics for higher-risk elderly patients 2