What questions should be asked for preoperative (pre-op) clearance?

Preoperative Clearance Questions: A Structured Approach

The preoperative evaluation must include three core components: comprehensive medical record review, patient/family interview with focused questions, and physical examination—not to "clear" the patient, but to assess current medical status and perioperative cardiac risk. 1

Critical Framework: What Preoperative Evaluation Is NOT

The ACC/AHA explicitly states that you should never use phrases like "cleared for surgery" in your consultation notes, as this oversimplifies your role and fails to communicate the nuanced cardiovascular risk assessment. 2 Your goal is to evaluate the patient's current medical status and provide a clinical risk profile that informs treatment decisions affecting short- and long-term cardiac outcomes. 1

Essential Questions to Ask: Medical Record Review

Active Cardiac Conditions (Absolute Contraindications)

Ask specifically about conditions that mandate stopping or postponing surgery: 1, 2

• Unstable coronary syndromes: "Do you have unstable angina, chest pain at rest, or chest pain with minimal activity?" (CCS Class III or IV angina) 1, 2
• Recent myocardial infarction: "Have you had a heart attack in the past 30 days?" 1, 2
• Decompensated heart failure: "Are you short of breath at rest, or has your shortness of breath worsened recently?" (NYHA Class IV or new-onset heart failure) 1, 2
• Significant arrhythmias: "Do you have an irregular heartbeat that causes symptoms like dizziness, fainting, or palpitations?" 1, 2
• Severe valvular disease: "Have you been told you have severe aortic stenosis or mitral stenosis?" 1, 2

Cardiovascular Risk Factors and Comorbidities

Document the following systematically: 1

• Prior cardiac history: "Have you ever had a heart attack, heart failure, or heart surgery?" 1
• Hypertension: "Do you have high blood pressure? Is it controlled?" 1
• Stroke history: "Have you ever had a stroke or TIA?" 1
• Diabetes mellitus: "Do you have diabetes? How is it controlled?" 1
• Peripheral vascular disease: "Do you have circulation problems in your legs?" 1
• Cerebrovascular disease: "Have you had problems with blood flow to your brain?" 1
• Renal impairment: "Do you have kidney problems?" 1
• Chronic pulmonary disease: "Do you have asthma, COPD, emphysema, or other lung problems?" 1

Functional Capacity Assessment

This is critical for risk stratification: 1, 2

• Ask directly: "Can you walk up two flights of stairs without stopping? Can you walk four blocks at a brisk pace?" (assessing 4 METs capacity) 1, 2
• Poor functional capacity (inability to perform 4 METs) warrants further evaluation in patients with clinical risk factors. 2

Essential Questions: Patient/Family Interview

Obstructive Sleep Apnea Screening

The ASA guidelines mandate specific OSA screening questions: 1

• Snoring: "Do you snore loudly?" 1
• Apneic episodes: "Has anyone witnessed you stop breathing during sleep?" 1
• Frequent arousals: "Do you frequently wake up during the night with vocalizations, position changes, or leg movements?" 1
• Morning headaches: "Do you wake up with headaches?" 1
• Daytime somnolence: "Are you excessively sleepy during the day?" 1
• Body mass index: Document BMI, as higher values are associated with OSA. 1

Airway History

Critical for anesthetic planning: 1

• Prior anesthetic difficulties: "Have you or any close relatives had problems with anesthesia or sedation?" 1
• Difficult intubation: "Have you been told you have a difficult airway?" 1

Medication History

Document all medications with exact dosages: 1

• Current medications: "List all prescription medications, including dosages and frequency." 1
• Over-the-counter drugs: "Are you taking aspirin, NSAIDs, or other over-the-counter medications?" 1
• Herbal supplements: "Are you taking any herbal or nutritional supplements?" 1
• Illicit drugs: "Do you use any recreational drugs?" 1
• Alcohol and tobacco: "How much alcohol do you drink? Do you smoke?" 1

Allergy History

Document specific reactions: 1

• Drug allergies: "Are you allergic to any medications? What happened when you took them?" 1
• Latex allergy: "Are you allergic to latex or adhesive tape?" 1

Recent Health Changes

This identifies unstable conditions: 1

• Change in symptoms: "Has there been any recent change in your health or symptoms?" 1
• New cardiac symptoms: In patients with established cardiac disease, any recent change in symptoms must be ascertained. 1

Essential Questions: Gender-Diverse Patients

For transgender and gender-diverse individuals, incorporate these questions into routine screening: 1

• Two-step gender question: "What sex were you assigned at birth? What is your current gender identity?" 1
• Preferred name and pronouns: "What name and pronouns do you prefer?" 1
• Hormone therapy: "Are you currently taking hormone therapy? What type and dose?" 1
• Prior gender-affirming surgeries: "Have you had any gender-affirming surgical procedures?" 1
• Pregnancy potential: For patients with potential to be pregnant, ask in a non-gendered way: "Is there any chance you could be pregnant?" 1

Physical Examination Priorities

Airway Assessment

Focus on predictors of difficult intubation: 1

• Nasopharyngeal characteristics 1
• Neck circumference 1
• Tonsil size 1
• Tongue volume 1

Cardiovascular Examination

Document baseline status: 1

• Blood pressure and heart rate 1
• Cardiac auscultation (though limited for diagnosing valvular disease) 3
• Signs of heart failure (edema, jugular venous distension) 1

When to Order Additional Testing

Order tests only if results will change the surgical procedure, alter medical therapy/monitoring, or lead to postponement until cardiac stabilization. 1, 2 Avoid redundant testing. 1, 2

Preoperative ECG Indications

• Patients with ≥1 clinical risk factor undergoing vascular surgery 1
• Patients with known coronary disease, peripheral arterial disease, or cerebrovascular disease undergoing intermediate-risk surgery 1

When Further Workup Is Required

• Poor functional capacity (<4 METs) in patients with clinical risk factors 2
• Suspected OSA with concerning features: jointly decide with surgeon whether to obtain sleep studies or manage based on clinical criteria alone 1

Common Pitfalls to Avoid

• Never say "cleared for surgery"—provide a comprehensive cardiovascular risk assessment instead. 2
• Don't order tests that won't change management—this wastes resources and potentially harms patients. 1, 2
• Don't skip OSA screening—undiagnosed OSA significantly increases perioperative risk. 1
• Don't forget to assess functional capacity—this is one of the strongest predictors of perioperative cardiac risk. 1, 2
• Don't overlook medication reconciliation—include herbals, supplements, and over-the-counter drugs. 1

Communication Requirements

Directly communicate findings with the surgeon, anesthesiologist, and patient/family. 1, 2 Document specific recommendations for: 2

• Medication changes
• Preoperative tests or procedures needed
• Higher levels of postoperative care required
• Whether the patient is in optimal medical condition within the context of their surgical illness 1, 2