What are reasons to not clear a patient for surgery?

Absolute Contraindications to Surgery

Surgery must be postponed or cancelled if any active cardiac condition is present, including unstable angina, recent myocardial infarction (within 30 days), decompensated heart failure, significant arrhythmias, or severe valvular disease. 1

Active Cardiac Conditions Requiring Cancellation

The following conditions mandate stopping elective surgery until evaluation and treatment are completed 2, 1:

• Unstable coronary syndromes: Unstable angina or severe angina (CCS Class III or IV) 1
• Recent myocardial infarction: Occurring more than 7 days but within 30 days of planned surgery 1
• Decompensated heart failure: NYHA Class IV heart failure, worsening symptoms, or new-onset heart failure 1
• Significant arrhythmias: High-grade atrioventricular block, symptomatic ventricular arrhythmias, newly recognized ventricular tachycardia, supraventricular arrhythmias with uncontrolled ventricular rate, or symptomatic bradycardia 1
• Severe valvular disease: Severe aortic stenosis or symptomatic mitral stenosis 1

Absolute Contraindications from Hemorrhagic Risk

Warfarin and anticoagulation therapy are contraindicated in any condition where the hazard of hemorrhage outweighs clinical benefits. 3 These include:

• Pregnancy: Warfarin crosses the placental barrier and causes fatal fetal hemorrhage and birth malformations 3
• Active bleeding: Gastrointestinal, genitourinary, or respiratory tract bleeding; cerebrovascular hemorrhage 3
• Recent or planned high-risk surgery: Central nervous system surgery, eye surgery, or traumatic surgery with large open surfaces 3
• Hemorrhagic tendencies: Blood dyscrasias, aneurysms (cerebral or dissecting aorta), pericarditis with effusions, bacterial endocarditis 3
• Spinal procedures: Spinal puncture or other procedures with uncontrollable bleeding potential 3

Conditions Requiring Delay Until Optimization

Poor Functional Capacity

Inability to perform 4 METs of activity (climbing one flight of stairs, walking on level ground at 4 mph) warrants further cardiac evaluation in patients with clinical risk factors before proceeding. 2, 1 This assessment directly predicts perioperative cardiac risk 2.

Acute Severe Ulcerative Colitis

In acute severe ulcerative colitis, delay in surgery beyond 7 days of failed rescue therapy increases surgical complications. 2 However, patients must first receive appropriate medical rescue therapy (infliximab or ciclosporin) unless complications develop (toxic megacolon, severe hemorrhage, perforation) 2.

Inadequate Anticoagulation Management

Elective surgery must be postponed if anticoagulation cannot be safely interrupted. 2 For DOAC-treated patients, surgery requires withholding for 2 full days (60-68 hours) before high-bleed-risk procedures, or 1 full day (30-36 hours) before low-to-moderate-bleed-risk procedures 2. Dabigatran-treated patients with impaired renal function (CrCl <50 mL/min) require 3-4 full days of interruption 2.

Pandemic or Resource Constraints

During COVID-19 pandemic peaks or when hospital/ICU capacity is overwhelmed, elective surgery must be suspended, performing only urgent/emergent cases. 2 Surgery should be postponed when 6-7 weeks may be necessary to see decreased viral prevalence 2.

Relative Contraindications Requiring Risk-Benefit Analysis

High-Risk Patient Populations

• Obesity and type 2 diabetes during viral pandemics: These patients face higher risk of severe complications from respiratory infections 2
• Elderly or debilitated patients: Require lower anticoagulation doses and more careful perioperative planning 3
• Patients with senility, alcoholism, psychosis, or lack of cooperation: Cannot be adequately supervised for safe perioperative management 3

Medication-Related Concerns

NSAIDs with half-lives longer than 6 hours increase postoperative bleeding complications (gastrointestinal bleeding and hypotension). 4 These should be stopped with sufficient time for drug elimination before elective surgery 4.

Antiplatelet therapy (aspirin, clopidogrel) should NOT be routinely discontinued, as the thrombotic risk of withdrawal overwhelms bleeding risk in most cases. 5 Exceptions include surgery in closed spaces (intracranial, spinal canal, posterior eye chamber) where only clopidogrel should be discontinued 5.

Critical Communication Requirements

Never use the phrase "cleared for surgery" in consultation notes—this oversimplifies the cardiovascular risk assessment and fails to communicate nuanced findings. 2, 1 Instead, document:

• Cardiovascular stability and whether the patient is in optimal medical condition within the surgical context 1
• Specific recommendations for medication changes, preoperative tests, or higher postoperative care levels 1
• Direct communication with surgeon, anesthesiologist, patient, and family 1

When Surgery Should Proceed Despite Risk

In acute surgical emergencies, limit evaluation to rapid assessment of vital signs, volume status, hematocrit, electrolytes, renal function, urinalysis, and ECG only. 1 The urgency of the surgical condition may outweigh cardiac optimization time 2.

For acute severe ulcerative colitis with complications (toxic megacolon, severe hemorrhage, perforation), subtotal colectomy must proceed immediately despite medical therapy failure. 2 Delay increases postoperative complications and mortality 2.