What are the general guidelines for giving clearance to patients for surgeries?

Preoperative Surgical Clearance: A Systematic Approach

The purpose of preoperative evaluation is NOT to simply "give medical clearance" but rather to perform a comprehensive assessment of the patient's current medical status, provide specific recommendations for perioperative risk management, and create a clinical risk profile for shared decision-making among the entire care team. 1, 2

Core Principle: Test Only What Changes Management

No test should be performed unless it is likely to influence patient treatment or perioperative management. 1, 2 The overriding theme is that preoperative intervention is rarely necessary simply to lower surgical risk unless such intervention is indicated irrespective of the surgical context. 1

Step 1: Identify Active Cardiac Conditions Requiring Immediate Attention

Screen for conditions that mandate delay of elective surgery: 1, 2

• Unstable coronary syndromes: Unstable or severe angina (CCS class III or IV), recent MI (within 30 days) 1
• Decompensated heart failure: NYHA class IV, worsening or new-onset HF 1
• Significant arrhythmias: High-grade AV block (Mobitz II or third-degree), symptomatic ventricular arrhythmias, uncontrolled atrial fibrillation (HR >100 bpm at rest), symptomatic bradycardia, newly recognized ventricular tachycardia 1
• Severe valvular disease: Severe aortic stenosis (mean gradient >40 mmHg, valve area <1.0 cm², or symptomatic), symptomatic mitral stenosis 1

If any active cardiac condition is present, delay elective surgery for cardiac stabilization or intervention. 2 Treatment decisions should be discussed in a multidisciplinary team. 2

Step 2: Assess Surgical Urgency and Risk

For Emergency Surgery:

Proceed with limited evaluation focusing only on: 1, 2

• Vital signs and volume status
• Hematocrit, electrolytes, renal function
• Urinalysis and ECG
• Conduct more thorough evaluation after surgery 1

For Elective Surgery - Classify Surgical Risk:

Low-risk procedures (<1% cardiac risk): Proceed without extensive cardiac workup 2

Intermediate/High-risk procedures: Continue systematic evaluation 2

Step 3: Obtain Targeted History

Identify specific cardiac and comorbid conditions: 1

• Cardiac history: Prior angina, MI, heart failure, arrhythmias, valvular disease, pacemaker/ICD, orthostatic intolerance 1
• Cardiovascular risk factors: Hypertension, diabetes, hyperlipidemia, smoking, age >75 3
• Associated diseases: Peripheral vascular disease, cerebrovascular disease, renal impairment, chronic pulmonary disease 1
• Current medications with exact dosages: Include herbal supplements, over-the-counter drugs, alcohol, tobacco, illicit drugs 1

Assess functional capacity in METs: 1, 3

• Can the patient run for 30 minutes daily? (high functional capacity - may need no further evaluation even if high-risk) 1
• Can the patient climb stairs, do housework, walk 4 mph? (≥4 METs) 1
• Sedentary patients with clinical risk factors require more extensive evaluation 1

Step 4: Physical Examination - Document Specific Findings

Record: 3

• Vital signs: Heart rate and blood pressure
• Cardiovascular examination: Heart sounds, murmurs, gallops
• Signs of heart failure: Jugular venous distension, peripheral edema, pulmonary rales

Step 5: Selective Testing Based on Risk

12-lead ECG: Obtain for patients with at least one clinical risk factor undergoing vascular surgical procedures 2

Left ventricular function assessment: Reasonable for patients with dyspnea of unknown origin or current/prior heart failure with worsening symptoms 2

Do NOT routinely order: 3

• Resting echocardiography
• Coronary CT angiography
• Stress testing Unless results will change perioperative management 3

Step 6: Preoperative Optimization (Minimum 4 Weeks Before Elective Surgery)

Mandatory interventions: 2

• Smoking cessation: Implement at least 4 weeks before surgery to reduce respiratory and wound-healing complications 2
• Alcohol abstinence: For patients consuming >2 units/day, strongly recommend 4-week preoperative abstinence 2
• Optimize chronic conditions: Diabetes control (target HbA1c <7%), hypertension management, heart failure optimization 2

For heart failure with LVEF <40%: Consider ACE inhibitors or ARBs before surgery 2

Beta-blocker considerations: 2

• May be considered for patients with known ischemic heart disease or myocardial ischemia
• Initiate between 30 days and minimum 2 days before surgery
• Start low dose, titrate to HR 60-70 bpm with systolic BP >100 mmHg
• Continue postoperatively

Step 7: Provide Specific Written Recommendations

Your consultation note must include: 2, 3

• Explicit statement: NOT "cleared for surgery" but specific perioperative recommendations 1, 3
• Perioperative medication management: Which medications to continue, discontinue, or adjust 3
• Monitoring recommendations: Level of postoperative care needed 1
• Risk assessment: Using validated tools like Revised Cardiac Risk Index 3
• Long-term cardiac risk reduction strategies 3

Step 8: Special Perioperative Medication Considerations

Warfarin management: For procedures requiring interruption, carefully weigh benefits and risks even for short periods 4

ACE inhibitors: Restart only after confirming patient is euvolemic to decrease perioperative renal dysfunction risk 2

Step 9: Communication and Patient Education

Direct communication required with: 1, 3

• Surgeon
• Anesthesiologist
• Primary physician
• Patient and family

Provide patients with: 2

• Clear information about perioperative risks for shared decision-making
• Dedicated preoperative counseling about surgical and anesthetic procedures
• Information in multiple formats (oral, written, multimedia) to reduce anxiety

Critical Pitfalls to Avoid

Never use the phrase "cleared for surgery" - this provides no actionable information and abdicates your responsibility to provide specific recommendations. 1, 3

Do not order tests that won't change management - this wastes resources and may lead to unnecessary interventions. 1, 2, 3

Do not miss the opportunity for long-term risk reduction - the preoperative evaluation may be the patient's first comprehensive cardiovascular assessment in years. 3

Ensure clear documentation - findings must be incorporated effectively into the patient's overall care plan. 1