What pre‑operative assessment and optimization steps are recommended before deciding on elective or emergent surgery for a patient with unknown age, comorbidities, presentation, and surgical procedure?

Pre-operative Assessment and Optimization for Surgery

All surgical patients require systematic risk stratification combining procedure-specific risk with patient-specific factors (age, comorbidities, frailty, functional capacity), followed by targeted optimization of modifiable risk factors balanced against the urgency of surgery. 1

Initial Risk Stratification Framework

Perioperative risk represents the combined effect of two distinct components: surgical procedure risk and patient-specific risk factors. 1, 2

Procedure-Specific Risk Assessment

• Classify surgery by risk level: low (<1% risk of major adverse cardiac events), intermediate, or high-risk based on invasiveness and hemodynamic stress 2
• Emergency surgery carries 2-5 times higher mortality than elective procedures, with postoperative mortality increasing from 1% in patients <60 years to 10% in those >80 years 1, 2
• Surgical timing categories: emergency (<2h), urgent (2-24h), time-sensitive (up to 3 months delay), or elective 2

Patient-Specific Risk Factors

Three independent patient factors drive perioperative risk: age-related physiological decline, multi-morbidity burden, and frailty status. 1, 2

• Age considerations: Physiological reserve decreases approximately 1% per year after age 40, but biological age differs from chronological age—age alone should not preclude surgery 1, 3
• Cardiac risk factors: unstable coronary syndromes, decompensated heart failure, significant arrhythmias, severe valvular disease, history of heart disease, cerebrovascular disease 2
• Other comorbidities: diabetes mellitus, renal insufficiency, chronic obstructive pulmonary disease, hypertension 2, 4
• Use validated risk prediction tools: Revised Cardiac Risk Index (RCRI) or American College of Surgeons NSQIP perioperative MI and cardiac arrest (MICA) risk calculator 2

Comprehensive Pre-operative Assessment Protocol

Mandatory Assessment Domains

Higher-risk patients require pre-operative assessment by both a senior geriatrician and a senior anesthesiologist with geriatric subspecialty training. 5, 1

Six mandatory domains must be evaluated: 1

1. Cognitive function: Screen for baseline dementia and delirium risk, as cognitive impairment increases postoperative delirium risk 3-fold 5, 6
2. Functional status: Assess using Duke Activity Status Index (DASI) or two-flight stairs test; poor functional capacity (inability to achieve 4 METs) indicates increased risk 2
3. Nutritional status: Identify malnutrition requiring pre-operative supplementation 5, 1
4. Polypharmacy: Review all medications for perioperative management, considering age-related pharmacokinetic/pharmacodynamic changes 5, 4
5. Comorbidity burden: Document all active medical conditions requiring optimization 5, 1
6. Social support: Assess discharge planning needs and caregiver availability 1

Frailty Assessment

Frailty provides unique prognostic information beyond traditional risk scores and shows dose-dependent effects on failure-to-rescue rates, postoperative complications, reoperation, and mortality. 1

• Screen all patients ≥65 years for frailty using a validated tool (Clinical Frailty Scale, modified frailty index) 1, 2
• Patients with Clinical Frailty Scale ≥5 require multidisciplinary geriatric assessment 1
• Failing to screen for frailty in patients ≥65 years is a critical error, as frailty is the strongest predictor of 12-month mortality 1

Cardiovascular Assessment

• All patients require pre-operative ECG 5
• Patients with audible cardiac murmur require echocardiogram 5
• Patients with recent myocardial infarction should not undergo elective surgery within 6 weeks 5
• Consider B-type natriuretic peptide level for additional risk stratification 2

Pulmonary Function Assessment (for thoracic surgery)

For lobectomy: No further testing needed if post-bronchodilator FEV1 >1.5 liters without interstitial lung disease 5

For pneumonectomy: No further testing needed if post-bronchodilator FEV1 >2.0 liters 5

If spirometry inadequate, proceed with Step 1: 5

• Full pulmonary function tests including transfer factor (TLCO)
• Oxygen saturation on room air at rest
• Quantitative isotope perfusion scan for pneumonectomy

Step 2 risk stratification: 5

• Average risk: Estimated postoperative FEV1 >40% predicted AND estimated postoperative TLCO >40% predicted AND oxygen saturation >90%
• High risk: Estimated postoperative FEV1 <40% predicted AND estimated postoperative TLCO <40%
• Uncertain risk: All other combinations require exercise testing

Step 3 exercise testing: 5

• High risk: Shuttle walk test <25 shuttles (250m) OR desaturation >4% during test
• Average risk: Peak oxygen consumption (VO2 peak) >15 ml/kg/min
• High risk: VO2 peak <15 ml/kg/min

Pre-operative Optimization Strategy

Optimization interventions must be balanced against surgical delay risks, as delays before hip fracture surgery and emergency laparotomy worsen outcomes. 1, 6

Modifiable Risk Factors

Screen for and optimize: 1, 2

• Smoking cessation: At least 4 weeks before surgery 1, 2
• Alcohol abstinence: 4 weeks prior to surgery 1, 2
• Anemia correction: Iron, vitamin B12, and folate supplementation started ≥28 days before elective surgery reduces morbidity and mortality 5, 6
• Nutritional optimization: Oral nutritional supplementation; avoid prolonged fasting 5, 6
• Diabetes control: Optimize glycemic management 2
• Hypertension management: Identify and treat undiagnosed hypertension 2

Organ-Specific Optimization

Focus on reducing postoperative complications: 5

• Ischemia prevention: Reduce oxygen uptake (analgesia, thermoregulation, antibiotics) and improve oxygen delivery (oxygen, fluids, medication review, avoid hypotension and severe anemia) 5
• Postoperative delirium prevention: Identify high-risk patients (very old, frail, cognitively impaired, cerebrovascular disease, multimorbidity/polypharmacy) and communicate throughout care team 5
• Cardiac optimization: Consider perioperative statin therapy for pleiotropic anti-inflammatory effects 2

Medication Management

• Review all medications for perioperative continuation, adjustment, or discontinuation 4
• Adjust dosing for age-related pharmacokinetic changes 6, 4
• Identify renal insufficiency to adjust opioid dosing and avoid NSAIDs 6

Emergency Surgery Considerations

Emergency elderly surgical patients require modified assessment protocols due to time constraints. 1

Rapid Assessment Protocol

• Obtain collateral history from family/caregivers during ambulance transport: document pre-morbid physical and cognitive status, medications, and next-of-kin 1
• Rapid access to geriatricians, anesthetists, intensivists, and surgeons within the emergency department to develop early intervention plans 1
• Concurrent optimization during surgical preparation is the correct approach—do not delay emergency surgery for optimization 1, 6

Modified Hemodynamic Thresholds

For frail elderly patients, use lower activation thresholds: heart rate >90 bpm, systolic BP <110 mmHg 1

Risk Communication and Decision-Making

Patients with predicted perioperative mortality >10% require intensive care admission and multidisciplinary discussion. 1, 6

• Provide realistic estimates of peri-operative mortality, life expectancy, and functional outcomes 7
• Consider patient's primary goals: prolongation of life versus maintenance of independence or symptom relief 7
• Written informed consent alone is insufficient—pre-operative information delivered orally better serves patients' needs 8
• Enhance communication by using structured conversations to ensure complete understanding before procedures 8

Critical Pitfalls to Avoid

• Do not ration surgical care based solely on chronological age—biological age and frailty status matter more 1, 3
• Do not delay emergency surgery for optimization—concurrent optimization is appropriate 1, 6
• Do not fail to screen for frailty in patients ≥65 years—it is the strongest predictor of poor outcomes 1
• Do not rely solely on written consent forms—oral communication is essential 8
• Do not omit functional capacity assessment—it is a critical predictor of adverse cardiovascular events 2
• Do not use age >80 as absolute contraindication to lobectomy or wedge resection for early-stage disease 5
• Exercise caution with pneumonectomy in elderly patients due to higher mortality risk 5