What are the guidelines for reviewing a patient before surgery?

Preoperative Review Guidelines for Surgery

All surgical patients require a structured preoperative assessment consisting of medical record review, patient/family interview, focused physical examination, and selective laboratory testing based on clinical indications—not routine protocols. 1, 2

Core Assessment Components

Medical Record Review

Review previous medical records to identify the following specific conditions 1:

• Cardiovascular disease: Prior MI, angina, heart failure, hypertension, coronary artery disease, stroke, carotid stenosis 1, 2
• Respiratory conditions: Obstructive sleep apnea, chronic lung disease, respiratory distress syndrome 1
• Metabolic/endocrine disorders: Diabetes mellitus, thyroid disease 1, 2
• Hematologic issues: Anemia, coagulopathies, bleeding disorders 1, 3
• Renal dysfunction: Chronic kidney disease, abnormal creatinine 2, 3
• Neurologic disease: Seizure disorders, cerebrovascular disease 1, 2
• Previous anesthesia complications: Difficult airway, adverse reactions to sedation/anesthesia, malignant hyperthermia 1
• Congenital syndromes: Down syndrome, acromegaly, neuromuscular disease 1

Patient/Family Interview

Conduct a focused interview addressing 1:

• Current medications: Include anticoagulants, antiplatelet agents, beta-blockers, diuretics, ACE inhibitors, psychotropic drugs 1, 2, 3
• Drug allergies and adverse reactions 1
• Substance use: Tobacco, alcohol, recreational drugs 1
• Sleep apnea screening: Snoring, witnessed apneic episodes, frequent arousals, morning headaches, daytime somnolence 1
• Functional capacity: Ability to climb ≥2 flights of stairs (≥4 METs indicates good capacity) 2, 4
• Pain tolerance and cooperation ability 1
• History of gastric bypass surgery 1

Focused Physical Examination

At minimum, examine 1:

• Vital signs: Blood pressure, heart rate, respiratory rate, oxygen saturation 1
• Airway assessment: Mallampati score, thyromental distance, neck mobility, mouth opening 1
• Cardiovascular: Heart auscultation for murmurs, irregular rhythms 1
• Pulmonary: Lung auscultation for wheezing, crackles 1
• Obesity markers: BMI, neck circumference (>17 inches in men, >16 inches in women suggests OSA risk) 1
• Nasopharyngeal characteristics: Tonsil size, tongue volume 1

Timing of Assessment

For high-risk patients or high-invasiveness procedures, complete the assessment days to weeks before surgery to allow optimization 1, 4. This includes 1, 4:

• Patients with ASA physical status ≥3 (severe systemic disease)
• High surgical invasiveness procedures (major vascular, intrathoracic, intraperitoneal)
• Patients with active cardiac conditions requiring stabilization

For low-risk patients undergoing minor procedures, assessment may occur on the day of surgery 1, 3.

Always reevaluate the patient immediately before the procedure 1.

Selective Laboratory Testing

When to Order Tests

Order tests only when clinically indicated—never routinely 2, 3, 4. Base decisions on patient comorbidities, physical findings, and surgical invasiveness 3.

Electrocardiogram (ECG)

Order ECG for 2, 3, 4:

• Patients with ≥1 cardiac risk factor undergoing vascular surgery
• Known CAD, peripheral arterial disease, or cerebrovascular disease undergoing intermediate-risk procedures
• Signs/symptoms of cardiovascular disease
• Do not order for asymptomatic patients undergoing low-risk surgery 3

Complete Blood Count (CBC)

Order CBC for 3, 4:

• Diseases increasing anemia risk (liver disease, hematologic disorders)
• History of anemia or recent blood loss
• Anticipated significant perioperative blood loss
• Cardiovascular surgery

Electrolytes and Renal Function

Order for 3:

• Medications predisposing to electrolyte abnormalities (diuretics, ACE inhibitors, ARBs, NSAIDs, digoxin)
• Hypertension, heart failure, chronic kidney disease, complicated diabetes, liver disease
• All neurosurgery and cardiovascular surgery patients

Coagulation Studies

Order for 3:

• Personal or family history of bleeding disorders
• Liver disease or conditions predisposing to coagulopathy
• Current anticoagulant use
• Do not order routinely—inherited coagulopathies have low prevalence 3

Chest X-ray

Order only for 3:

• New or unstable cardiopulmonary signs/symptoms
• Risk of postoperative pulmonary complications where results would change management
• Do not order routinely for asymptomatic patients 3

Urinalysis

Order only for 3:

• Urologic procedures
• Implantation of foreign material (prosthetic joint, heart valve)
• Do not order routinely 3

Special Population Considerations

Obstructive Sleep Apnea Patients

Identify OSA patients early to formulate perioperative management plans 1. If clinical evaluation suggests OSA, jointly decide with the surgeon whether to 1:

1. Manage based on clinical criteria alone, or
2. Obtain formal sleep studies and initiate OSA treatment before surgery

Spine Surgery Patients

Inform patients undergoing spine surgery about perioperative visual loss (POVL) risk, especially those with 1:

• Male gender, obesity, vascular disease risk factors
• Anticipated prolonged procedures or substantial blood loss
• Preoperative anemia

Cataract Surgery Patients

Routine preoperative medical testing is not indicated for cataract surgery patients in their usual state of health 1, 3, 4. Three randomized trials confirm this does not reduce complications 1.

Critical Pitfalls to Avoid

• Never order tests "just to be safe" or based on arbitrary age cutoffs 3
• Do not delay assessment until day of surgery for high-risk patients 4
• Avoid routine testing protocols—only order tests that would alter perioperative care 3, 4
• Do not rely solely on "cleared for surgery" consultations—document specific recommendations 4
• Recognize that adverse outcomes can occur even in optimized patients—preexisting conditions increase but do not guarantee complications 1

Documentation Requirements

Document the following in your preoperative note 4:

• Patient age, planned procedure, surgical risk classification
• ASA physical status (1-5)
• Current diagnoses with emphasis on active cardiac conditions
• Functional capacity in METs
• All relevant test results (ECG, labs)
• Risk stratification and perioperative recommendations
• Timing of assessment relative to surgery date