Is the patient medically fit for the planned surgery?

Can Surgery Proceed? Preoperative Medical Fitness Assessment

Yes, surgery can proceed if the patient meets specific criteria based on a stepwise algorithmic approach that prioritizes active cardiac conditions, surgical risk, and functional capacity. 1

Step 1: Screen for Active Cardiac Conditions That Mandate Delay

Surgery must be cancelled or delayed if any of the following active cardiac conditions are present: 1

• Unstable coronary syndromes (unstable or severe angina, recent MI with evidence of important ischemic risk)
• Decompensated heart failure or new/poorly controlled ischemia-mediated heart failure
• Severe arrhythmias
• Severe valvular heart disease

If any active cardiac condition exists, refer for coronary angiography and cardiac optimization before reconsidering surgery. Depending on interventions performed and urgency of surgery, proceeding with maximal medical therapy may be appropriate after cardiac treatment. 1

If no active cardiac conditions are present, proceed to Step 2. 1

Step 2: Determine Surgical Risk Category

For low-risk surgery (combined morbidity/mortality <1%), proceed directly to surgery regardless of cardiac history or risk factors. 1, 2

Low-risk procedures include cataract surgery, endoscopy, superficial procedures, and most ambulatory surgeries. 2 Cardiovascular testing in stable patients undergoing low-risk surgery rarely changes management and is not indicated. 1, 2

For intermediate-risk or high-risk surgery, proceed to Step 3. 1, 3

Step 3: Assess Functional Capacity

If the patient can achieve ≥4 METs without symptoms, proceed to surgery. 1, 3

Functional capacity ≥4 METs is defined as the ability to: 1

• Walk 4 blocks (approximately 0.5 miles)
• Climb 2 flights of stairs
• Perform moderate cycling
• Engage in activities requiring similar exertion

Patients unable to meet 4-MET demand have significantly increased perioperative cardiac risk and require further evaluation. 1, 3

For patients with good functional capacity (≥4 METs) who have known cardiovascular disease or ≥1 clinical risk factor, implement perioperative heart rate control with beta-blockade. 1, 3

Step 4: Risk Factor Assessment for Poor Functional Capacity

If functional capacity is <4 METs, symptomatic, or unknown, count the number of clinical risk factors present: 1

Clinical risk factors include:

• Ischemic heart disease
• Compensated or prior heart failure
• Diabetes mellitus
• Renal insufficiency (creatinine >2 mg/dL)
• Cerebrovascular disease

With 0 clinical risk factors: proceed to surgery. 1

With 1-2 clinical risk factors: either proceed with surgery using heart rate control with beta-blockade, or consider noninvasive testing if it will change management. 1, 3

With ≥3 clinical risk factors undergoing vascular surgery: consider noninvasive testing only if it will change management. 1

With ≥3 clinical risk factors undergoing intermediate-risk nonvascular surgery: insufficient data exists, but reasonable to either proceed with tight heart rate control or perform testing if it will change management. 1

Additional Considerations for Lung Resection Surgery

For patients being considered for thoracotomy or lung resection, additional pulmonary and nutritional assessments are mandatory: 1, 4

Pulmonary Fitness Criteria:

• Proceed with lobectomy if post-bronchodilator FEV₁ >2.0 liters without interstitial lung disease or unexpected disability. 1
• For all others, calculate estimated postoperative FEV₁ and TLCO (both as % predicted). 1
• Average risk: estimated postoperative FEV₁ >40% predicted AND estimated postoperative TLCO >40% predicted AND oxygen saturation >90% on room air. 1
• High risk: estimated postoperative FEV₁ <40% predicted OR estimated postoperative TLCO <40% predicted. 1

Nutritional Status:

Measure body mass index and serum albumin preoperatively. Low values significantly increase postoperative complications including poor wound healing and infection. 1, 4

Patients with preoperative weight loss ≥10% and/or WHO performance status ≥2 require particularly careful staging and co-morbidity assessment, as they likely have advanced disease. 1

Cardiovascular Assessment for Thoracic Surgery:

• All patients require preoperative ECG. 1
• Patients with audible cardiac murmur require echocardiogram. 1
• Do not operate within 6 weeks of myocardial infarction. 1
• Patients with MI within 6 months require cardiology consultation before proceeding. 1

Empyema-Specific Considerations:

Before proceeding to thoracotomy with decortication, document failure of conservative management (persistent sepsis and pleural collection despite 7 days of chest tube drainage, antibiotics, and intrapleural fibrinolytics). 4

Common Pitfalls to Avoid

Do not order routine preoperative testing (ECG, echocardiography, stress testing) for low-risk surgery in asymptomatic patients—this increases costs without improving outcomes. 2

Do not reflexively order cardiovascular testing based on laboratory abnormalities alone (such as elevated creatinine) without considering the surgical risk category. 2

Do not delay surgical referral beyond 7 days of failed medical management in empyema cases, as persistent sepsis mandates thoracic surgery consultation. 4

For patients with multiple adverse medical factors who are anatomically suitable for resection, formal multidisciplinary discussion between chest physician, surgeon, and oncologist is mandatory before proceeding. 1