What is required for primary care preoperative (pre-op) clearance for surgery and what information should be sent to the surgical team?

Preoperative Clearance Requirements for Primary Care

Your preoperative evaluation should be driven by a focused history and physical examination targeting cardiac and pulmonary risk factors, not by routine testing—and you must send a comprehensive risk assessment note documenting the patient's current medical status, active conditions, functional capacity, and perioperative recommendations to the surgical team. 1

Core Components You Must Assess

History Taking - Focus on These Specific Elements:

• Cardiovascular disease: Prior MI, angina, heart failure symptoms, arrhythmias, presence of pacemaker/ICD, orthostatic intolerance 1
• Pulmonary disease: Dyspnea, chronic lung disease, current respiratory symptoms 1
• Functional capacity: Can the patient climb 2 flights of stairs or walk 4 blocks without symptoms? (≥4 METs indicates good functional capacity) 2
• Active cardiac conditions requiring immediate attention: Unstable coronary syndromes, decompensated heart failure, significant arrhythmias, severe valvular disease 1, 2
• Comorbidities: Diabetes (especially insulin-dependent), cerebrovascular disease, renal dysfunction (creatinine >2 mg/dL), peripheral vascular disease 1
• Medication history: Anticoagulants, antiplatelet agents, beta-blockers, insulin 1
• Prior surgical/anesthetic complications 1

Physical Examination - These Specific Findings Matter:

• Airway assessment (mandatory for all patients) 1
• Pulmonary examination with lung auscultation 1
• Cardiovascular examination including heart auscultation 1
• Vital signs documentation 1
• Signs of heart failure: JVD, peripheral edema, rales 1

Selective Testing Based on Clinical Findings

Do NOT order routine batteries of tests—testing is only indicated when findings would change perioperative management. 1

ECG Indications:

• Order for: Patients with ≥1 cardiac risk factor undergoing vascular surgery 1
• Order for: Known CAD, peripheral arterial disease, or cerebrovascular disease undergoing intermediate-risk procedures 1
• Order for: Signs/symptoms of cardiovascular disease 1
• Do NOT order for: Asymptomatic patients undergoing low-risk procedures 1

Laboratory Testing - Only When Indicated:

• CBC: Only for patients with diseases causing anemia OR anticipated significant blood loss 1
• Coagulation studies: Only for patients on anticoagulants, bleeding history, or conditions predisposing to coagulopathy (e.g., liver disease) 1
• Electrolytes/Creatinine: Only for patients at risk of electrolyte abnormalities or renal impairment 1
• Glucose/A1C: Only if abnormal results would change perioperative management 1

Chest X-ray:

• Order only for: New or unstable cardiopulmonary signs/symptoms 1
• Do NOT order routinely 1

Urinalysis:

• Order only for: Urologic procedures or implantation of foreign material 1

Special Cardiac Testing:

• LV function assessment: Reasonable for dyspnea of unknown origin OR worsening heart failure symptoms 1, 2
• Stress testing: May be reasonable for elevated cardiac risk with poor functional capacity IF results would change management 2

What You Must Send to the Surgical Team

Your consultation note is NOT "medical clearance"—it is a comprehensive risk assessment. 1

Required Documentation to Send:

1. Current medical diagnoses with severity and stability 1, 3
2. Active cardiac conditions requiring optimization before surgery 2
3. Functional capacity assessment (METs equivalent) 2
4. Current medications including anticoagulation status 1, 3
5. Perioperative risk profile based on patient factors and surgical invasiveness 1
6. Specific recommendations for:
   • Medication management (continue/hold/adjust) 3
   • Need for further cardiac evaluation if indicated 1
   • Optimization strategies for chronic conditions 2
7. Test results if obtained (ECG, labs, imaging) 1
8. Estimated perioperative cardiac risk 1

Timing Considerations:

• High surgical invasiveness: Complete assessment and medical record review BEFORE day of surgery 1
• High severity of disease: Interview and physical exam BEFORE day of surgery 1
• Low-risk procedures in healthy patients: May be done on day of surgery 1

Critical Pitfalls to Avoid

Do not order tests "just to be safe"—this delays surgery, increases costs, and often leads to false positives requiring unnecessary follow-up. 1

• Avoid: Routine preoperative testing in asymptomatic patients 1
• Avoid: Stating "cleared for surgery"—instead provide risk assessment 1
• Avoid: Ordering coronary revascularization solely to "get through" surgery (only indicated if needed independent of surgery) 1
• Exception: Patients in usual health undergoing cataract surgery need NO preoperative testing 1

Ensure optimal medical therapy for known cardiovascular disease before proceeding. 2