What is involved in surgical clearance for a patient?

Surgical Clearance: A Comprehensive Approach

Surgical clearance is not simply about giving medical approval but involves a thorough evaluation of the patient's current medical status, risk assessment, and recommendations for perioperative management to optimize outcomes related to morbidity, mortality, and quality of life. 1, 2

Purpose of Surgical Clearance

• The primary goal is to perform an evaluation of the patient's current medical status and make recommendations for the entire perioperative period 1
• Surgical clearance should identify potential risks and provide a clinical risk profile that all healthcare providers can use in making treatment decisions 1
• The evaluation should avoid unnecessary testing while focusing on identifying conditions that may increase perioperative risk 1, 2

Essential Components of Surgical Clearance

History and Physical Examination

• A careful history is crucial to identify serious cardiac conditions such as unstable coronary syndromes, prior angina, recent MI, decompensated heart failure, significant arrhythmias, and severe valvular disease 1
• Document current medications including herbal supplements, and note any history of pacemaker, ICD, or orthostatic intolerance 1, 2
• Assess the patient's functional capacity in METs (metabolic equivalents) which correlates with maximum oxygen uptake and helps determine perioperative risk 1, 2
• Identify modifiable risk factors such as hypertension, diabetes, hyperlipidemia, and smoking 2
• Document use of alcohol, tobacco, and over-the-counter or illicit drugs 1

Cardiovascular Assessment

• Evaluate for active cardiac conditions that may require delaying surgery (see Table 2 in guidelines) including:
  • Unstable or severe angina
  • Recent myocardial infarction
  • Decompensated heart failure
  • Significant arrhythmias
  • Severe valvular disease 1
• Perform a comprehensive cardiovascular examination including heart sounds, murmurs, gallops, and signs of heart failure 2
• Record vital signs including heart rate and blood pressure 2

Laboratory and Diagnostic Testing

• Order preoperative tests only if they will result in a change in the surgical procedure, medical therapy, monitoring, or postponement of surgery 1, 2
• Include ECG findings with date in the clearance note for appropriate patients 2
• Consider echocardiogram results if relevant, including LVEF, wall motion, and valvular function 2
• The American College of Cardiology recommends against routine preoperative resting echocardiography, coronary CT angiography, or stress testing unless it will change management 2

Risk Assessment and Stratification

• Assess surgical risk category (low, intermediate, or high) 2
• Calculate risk scores such as the Revised Cardiac Risk Index (RCRI) when applicable 2, 3
• Evaluate the patient's ability to perform daily activities in METs to determine functional capacity 1
• For urgent/emergency surgery, proceed with limited evaluation focusing on vital signs, volume status, hematocrit, electrolytes, renal function, and ECG 3

Special Considerations

• Delay elective surgery for at least 6 weeks after bare metal stent placement and at least 12 months after drug-eluting stent placement 2
• Manage antiplatelet therapy carefully in patients with recent coronary interventions 2
• Consider perioperative beta-blocker therapy in patients with known ischemic heart disease 3
• For patients on warfarin, determine if interruption is necessary and plan appropriate bridging therapy 4

Clear Recommendations and Communication

• Provide explicit statement of clearance status (cleared, not cleared, or cleared with specific precautions) 2
• Avoid phrases like "clear for surgery" which do not provide specific recommendations 1, 2
• Include perioperative medication management recommendations 2
• Provide parameters for seeking immediate cardiac consultation if needed 2
• Ensure clear communication with all providers, including direct communication with surgeon, anesthesiologist, and other physicians 1, 2

Common Pitfalls to Avoid

• Viewing preoperative evaluation as simply "giving medical clearance" rather than a comprehensive risk assessment 1, 2, 3
• Performing tests that will not influence perioperative management 2, 3
• Missing the opportunity for long-term risk reduction 2
• Failing to communicate findings and recommendations to all members of the perioperative team 2

Optimization Strategies

• Consider smoking cessation at least 4 weeks before surgery to reduce respiratory and wound-healing complications 3
• Recommend preoperative abstinence from alcohol for 4 weeks for patients consuming more than two units of alcohol per day 3
• Optimize diabetes, hypertension, and other medical conditions before elective surgery 3, 5
• For patients with heart failure and systolic LV dysfunction (LVEF <40%), consider ACEIs or ARBs before surgery 3

By following this comprehensive approach to surgical clearance, clinicians can effectively evaluate patients' perioperative risks and optimize their care to improve outcomes related to morbidity, mortality, and quality of life 6, 7.