What are the key components of preoperative care in an inpatient setting?

Preoperative Care in the Inpatient Setting

Inpatient preoperative care should focus on comprehensive risk stratification and aggressive optimization of modifiable risk factors through a multidisciplinary team approach, with particular emphasis on identifying high-risk patients who may benefit from a "surgical pause" to mitigate perioperative morbidity and mortality. 1

Risk Stratification and Patient Identification

The first priority is identifying patients at high risk for poor surgical outcomes using structured assessment tools:

• Assess functional capacity using the 4 MET threshold (ability to climb ≥2 flights of stairs); patients meeting this threshold can generally proceed without extensive cardiac testing 2
• Screen for major risk factors including functional dependence, chronic obstructive pulmonary disease, congestive heart failure, recent weight loss, and obstructive sleep apnea—all significantly increase postoperative pulmonary complications 2
• Evaluate frailty and cognitive status systematically, as these predict adverse outcomes and guide perioperative planning 1
• Perform delirium screening preoperatively to identify at-risk patients who require targeted prevention strategies 1

Modifiable Risk Factor Optimization

Smoking Cessation

• Mandate complete cessation at least 4 weeks before elective surgery to achieve meaningful reductions in respiratory and wound-healing complications 1, 3
• Ideally target 6-8 weeks of abstinence for maximal cardiopulmonary benefit 3
• Implement intensive interventions combining face-to-face or telephone counseling with nicotine replacement therapy or varenicline starting at initial surgical consultation 3
• Critical caveat: Shorter durations provide no measurable benefit—there is a clear threshold effect at 4 weeks 3

Alcohol Cessation

• Require 4 weeks of complete abstinence for patients consuming more than 2 units daily, as this reduces postoperative infections 1
• Alcohol drives immune suppression and worsens the catabolic stress response perioperatively 1

Anemia Management

• Screen at least 4 weeks before surgery using complete blood count, serum ferritin, and transferrin saturation 2
• For moderate-to-severe anemia, prioritize intravenous iron therapy, especially when surgery is scheduled within 2-3 weeks 2
• Preoperative anemia increases complications, transfusion rates, mortality, and may worsen oncologic outcomes 1

Nutritional Optimization

• Conduct formal nutritional assessment for all patients, with particular attention to malnutrition markers 1
• Weight management and nutritional intervention reduce long-term risks of diabetes, stroke, and cardiovascular disease 1

Chronic Disease Management

• Optimize diabetes control with appropriate perioperative glucose management protocols 2
• Control hypertension through medication adjustment and monitoring 1
• Manage chronic pain and opioid use preoperatively to reduce postoperative complications 1

Special Populations

• Geriatric patients require dedicated pathways addressing polypharmacy, cognitive decline risk, and functional status 1
• In high HIV-prevalence regions, perform routine preoperative HIV testing to identify patients requiring antiretroviral optimization 1

Comprehensive Patient Education

• Provide education in oral, written, and pictorial formats to both patient and a family member or caregiver 1
• Education should cover: surgical and anesthetic procedures, expected recovery timeline, pain management strategies, early mobilization goals, feeding expectations, and discharge planning 1
• Establish clear emergency contact details and transportation plans preoperatively, particularly important for patients with limited access to healthcare 1
• This reduces anxiety, pain, nausea, and improves patient satisfaction while facilitating early discharge 1

Preoperative Testing and Assessment

Cardiovascular Evaluation

• Obtain ECG for patients with signs/symptoms of cardiovascular disease or undergoing high-risk surgery 2
• Patients with good functional capacity (≥4 METs) generally do not require further cardiac testing 2

Laboratory Testing

• Order CBC for patients with anemia history, recent blood loss, liver disease, hematologic disorders, or undergoing cardiovascular/major surgery 2
• Check electrolytes and renal function for patients with known renal conditions, those undergoing neurosurgery/cardiovascular surgery, or taking medications affecting electrolytes 2
• Avoid routine testing—order only when clinically indicated by patient status or surgical procedure 2, 4

Pulmonary Assessment

• Do not routinely order chest radiography for asymptomatic patients 2
• Consider imaging only for new or unstable cardiopulmonary symptoms 2

Preoperative Protocols

Fasting Guidelines

• Allow clear liquids until 2 hours before induction 1, 2
• Permit light meals until 6 hours before induction 1, 2
• Require 8+ hours fasting after full meals (including meat, fatty, or fried foods) 1

Carbohydrate Loading

• Administer 400 mL complex carbohydrate drink (50g CHO, 12g/100mL, osmolality <300 mOsm/kg) 2 hours before surgery for non-diabetic elective patients 1

Mechanical Bowel Preparation

• Avoid routine mechanical bowel preparation for elective colonic or gynecologic surgery 1
• This practice causes dehydration, electrolyte abnormalities, patient dissatisfaction, and increased anxiety without proven benefit 1

Premedication

• Avoid routine premedication with long-acting sedatives 1
• Consider short-acting anxiolytics only for severe anxiety, as routine use delays psychomotor recovery and increases delirium risk 1

Multidisciplinary Team Approach

The most effective model involves an anesthesiologist-directed team including surgeons, primary care providers, and specialists working collaboratively with the patient in shared decision-making 1. This team should:

• Provide a "surgery coach" specifically trained in surgical preparation who mentors high-risk patients 1
• Utilize machine-learning predictive algorithms and protocol-driven care to identify patients requiring surgical pause for risk mitigation 1
• Coordinate care throughout the perioperative continuum, not just the immediate surgical episode 1

Critical Implementation Considerations

Common pitfall: Focusing solely on the immediate surgical episode rather than long-term patient outcomes. The choice of anesthetic agent matters far less than optimizing modifiable risk factors like obesity, malnutrition, and chronic disease 1.

Key principle: For high-risk patients undergoing non-urgent surgery, consider a "surgical pause" to allow time for comprehensive optimization of physiologic and psychosocial conditions 1. This approach transforms reactive medicine into preventative medicine, potentially avoiding the need for future, more invasive procedures 1.