What are the key considerations for the care of a preoperative patient?

Preoperative Patient Care: Key Considerations

For elective surgery, optimize medical conditions (anemia, diabetes, hypertension), mandate smoking and alcohol cessation 4 weeks preoperatively, assess nutritional status with supplementation for malnourished patients, provide clear fluid intake until 2 hours before surgery, and avoid routine preoperative testing unless specific risk factors are identified. 1

Preoperative Optimization (4 Weeks Before Surgery)

Medical Condition Management

• Screen and optimize anemia before surgery, as malnourished patients have limited nutritional stores and benefit from preoperative supplementation with fewer infectious complications and anastomotic leaks 1
• Mandate smoking cessation at least 4 weeks before surgery—this improves surgical outcomes across 11 randomized controlled trials involving 1,194 patients 1
• Require alcohol cessation for heavy drinkers (>24 g/day for women, >36 g/day for men) 4-8 weeks preoperatively, as hazardous alcohol intake increases postoperative infections, cardiopulmonary complications, and bleeding episodes 1
• Control hypertension and diabetes through screening and optimization 1
• In high HIV prevalence countries, perform routine HIV screening and optimize antiretroviral therapy before surgery 1

Nutritional Assessment

• Assess all patients for malnutrition using these criteria: weight loss >10% or >5% over 3 months, reduced body mass index, or low fat-free mass index 1
• Provide enteral supplementation for 7-14 days preoperatively in malnourished patients 1
• Consider prehabilitation programs (physical exercise to increase functional capacity) 4-6 weeks before surgery, though outcome benefits remain under evaluation 1

Cardiovascular Risk Assessment

History and Physical Examination

• Determine cardiovascular history: hypertension, coronary artery disease, arrhythmia, cerebrovascular accident, peripheral arteriopathy, prior revascularization procedures 1
• Identify cardiac symptoms: atypical presentations like dyspnea or exercise-induced epigastric pain, orthostatic or postprandial hypotension, serious unfelt hypoglycemia episodes 1
• Assess functional capacity in metabolic equivalents (METs) 1
• Perform orthostatic blood pressure testing and examine for critical lower limb ischemia 1

Cardiovascular Testing

• Obtain ECG in patients with signs or symptoms of cardiovascular disease, not based solely on age 1
• For major surgery with Lee score ≥2 and functional capacity <4 METs, refer to cardiology for ischemia testing 1
• Avoid routine preoperative testing in low-risk surgery patients in their usual state of health 1

Diabetic Patients Require Special Attention

• Assess for cardiac autonomic neuropathy (CAN): permanent tachycardia, QTc >440 ms, myocardial infarction, orthostatic hypotension, serious unfelt hypoglycemia, absence of nocturnal blood pressure decrease 1
• Evaluate respiratory heart rate variability, as decreased variability predicts perioperative hemodynamic instability 1

Preoperative Fasting and Carbohydrate Loading

Fasting Guidelines

• Allow clear fluids until 2 hours before anesthesia induction 1
• Allow light meals until 6 hours before induction 1
• Require 8+ hours fasting after full meals containing meat, fatty, or fried foods 1

Carbohydrate Loading

• Administer 400 mL carbohydrate drink (50 g CHO, 12 g/100 mL, osmolality <300 mOsm/kg) the evening before surgery and 2-4 hours before induction 1
• This improves perioperative insulin resistance though impact on length of stay in liver surgery remains unclear 1

Preoperative Medications and Prophylaxis

Medications to Avoid

• Avoid long-acting sedatives and anxiolytics, particularly in elderly patients, as they delay return to full psychomotor function and increase delirium risk 1
• Do not routinely use preoperative gabapentinoids or NSAIDs 1
• Avoid preoperative hyoscine patches in elderly patients despite their benefit for postoperative nausea and vomiting in younger high-risk patients 1

Antibiotic Prophylaxis

• Administer first-generation cephalosporin (cefazolin) within 60 minutes before surgical incision 1
• Do not extend antibiotics into the postoperative period for routine prophylaxis 1
• For complex liver surgery with biliary reconstruction, consider targeted preemptive antibiotics based on preoperative bile culture, though duration is unknown 1

Thromboembolism Prophylaxis

• Apply intermittent pneumatic compression devices before anesthesia induction 1, 2
• Start low molecular weight heparin or unfractionated heparin postoperatively (not preoperatively) unless exceptional circumstances make this unsafe 1, 2
• Continue thromboprophylaxis throughout hospitalization using combination of compression stockings/devices and pharmacologic agents 1

Preoperative Education and Counseling

Patient and Family Education

• Provide preoperative counseling in oral, written, and pictorial formats to the patient and a caregiver 1
• Establish clear expectations about surgical and anesthetic care plans, recovery timeline, and discharge plans 1
• Ensure patients understand their role in successful recovery, as ERAS patients are discharged in an intermediate recovery phase 1
• Provide clear emergency contact details and transport plans, particularly important in resource-limited settings with long travel distances 1
• This reduces patient anxiety, pain, nausea/vomiting and increases satisfaction 1

Preoperative Testing: When to Order

Laboratory Testing

• Avoid routine preoperative laboratory testing—extensive systematic reviews show no evidence supporting this practice 1
• Order electrolytes and creatinine only in patients at risk of electrolyte abnormalities or renal impairment 1
• Obtain complete blood count only in patients at risk of anemia based on history/examination or when significant blood loss is anticipated 1
• Perform coagulation testing only in patients taking anticoagulants, with bleeding history, or conditions predisposing to coagulopathy (e.g., liver disease) 1
• Consider glucose or A1C measurement only if abnormal results would change perioperative management 1

Imaging

• Obtain chest radiography only in patients with new or unstable cardiopulmonary signs or symptoms 1
• Avoid routine chest X-rays in asymptomatic patients 1

Urinalysis

• Perform urinalysis only for patients undergoing urologic procedures or implantation of foreign material 1

Procedure-Specific Considerations

Bowel Preparation

• Avoid routine mechanical bowel preparation for elective colonic or gynecologic surgery, as it causes dehydration, electrolyte abnormalities, interrupted sleep, and increased anxiety without reducing infection or anastomotic leaks 1
• Consider selective use only for elective low rectal surgery or planned defunctioning stomas 1

Biliary Drainage (Liver Surgery)

• Perform biliary drainage when bilirubin >50 mmol/L 1
• Prefer percutaneous over endoscopic drainage for perihilar cholangiocarcinoma 1
• Delay surgery until bilirubin drops below 50 mmol/L 1

Steroid Administration (Liver Surgery)

• Administer methylprednisolone 500 mg preoperatively for liver resection 1

Common Pitfalls to Avoid

• Do not perform extensive preoperative testing for low-risk surgeries (cataract, dental, endoscopic procedures, skin biopsies)—this rarely improves care and increases costs 1
• Do not rely on age alone to determine need for ECG; use cardiovascular risk assessment instead 1
• Do not keep patients NPO from midnight—this outdated practice lacks evidence and causes unnecessary dehydration 1
• Do not routinely premedicate with long-acting sedatives—this delays recovery and increases delirium, especially in elderly patients 1
• Do not start thromboprophylaxis preoperatively for liver surgery—begin postoperatively to balance bleeding and thrombotic risks 1, 2
• Do not use traditional coagulation tests (INR, PT) to predict bleeding risk in hepatectomy patients, as they often overestimate risk 2