Pre-operative assessment

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Mohammed A. Sbeih, M.D.[2] Phone:617-849-2629

Overview

The goal of medical preoperative clearance is to assess medical problems in the patients to identify unrecognized co-morbid diseases and optimize preoperative medical condition, also the preoperative medical assessment helps the doctors to decide if the patient is suitable for the proposed surgery according to the patient's risk category, and identify the factors that may reduce the patient risk and provide recommendations for post-operative care. Preoperative clearance usually starts by identifying the type of surgery to be performed and the risk category of the patient who need this surgery.

Perioperative risk of death

Patients can be divided into different risk categories based on the basis of their preoperative medical assessment. this helps the doctors to decide if the patient is suitable for the proposed surgery or procedure, and identify the factors that may reduce the patient risk. There are many factors that may influence the patient risk of complications, including death.

• Anesthesia

Although the modern anesthesia is safe the risk varies according to the type of Anesthesia (general or regional anesthesia).

Patient and surgical factors are more important risk predictors.

The American society of anesthesiologists (ASA) Classification is a predictor of preoperative mortality. It also predicts cardiac and pulmonary morbidity.

ASA classification

Class	Systemic disturbance	Mortality
1	Healthy patient with no disease outside of the surgical process	<0.03%
2	Mild-to-moderate systemic disease caused by the surgical condition or by other pathologic processes	0.2%
3	Severe disease process which limits activity but is not incapacitating	1.2%
4	Severe incapacitating disease process that is a constant threat to life	8%
5	Moribund patient not expected to survive 24 hours with or without an operation	34%
E	Suffix to indicate an emergency surgery for any class	Increased

• Type of procedure or surgery

Perioperative risk of complications varies according to the type of surgery.

• Patient age

• Emergency procedure

In emergency procedures the risk of complications may increases two to four times, or even more than that in elderly patients.

• Pulmonary factors

There are several pulmonary factors that may increase the risk of surgical patients, these may include:

• Cigarete smoking.
• Respiratory diseases.
• Abnormal chest x-ray or phisical examination findings.
• Thoracic or upper abdominal surgery.
• Morbid obesity.
• Age over 60.

• Cardiac factors

There are several cardiac factors that may increase the risk of surgical patients, these may include:

• History of prosthetic valves.
• History of rheumatic fever.
• Congestive heart failure.
• Arrhithmia.

Preoperative clinical evaluation

In general, the overall risk of surgery is extremely low in healthy individuals.

History

• The patient should be asked about his age.Some studies found a small increased risk of surgery associated with advancing age. Mortality risk increased linearly with age :for most surgical procedures due to increasing numbers of comorbidities with advancing age.

• The patient should be asked if he had a history of:

• Heart diseases,irregular heart beat, murmurs or rheumatic fever as a child.
• Pulmonary diseases such as asthma, bronchitis, or emphysema.
• Chest pain, angina, or chest tightness.
• Hypertension or hypotension.
• Shortness of breath, cough.
• Liver diseases, jaundice or hepatitis.
• Gastrointestinal problems or indigestion.
• Diabetes.
• Thyroid problems.
• Kidney problems.
• Weakness or numbness in the arms or legs.
• Seizures or blackouts.
• Bleeding disorders.
• Blood clot abnormality.
• Arthritis or joint pain.

• The patient should be asked if he/she:

• Have any allergies for food or medication.
• Have a list of any medications he is currently taking, including over-the-counter medications. Nonsteroidal anti-inflammatory drugs are associated with an increased risk :of perioperative bleeding.
• Had any other medical conditions in the past.
• Had any previous surgeries or anesthesia.
• May be pregnant.
• Have taken steroid medications before.
• Had any problem with a previous anesthetic.

• The patient should be asked when did he last eat or drink at the day of surgery.
• The patient should be asked about his Height and Weight. Studies showed that obesity is not a risk factor for most adverse postoperative outcomes, with the exception of :deep venous thrombosis and pulmonary embolism. However, some cardiac surgery studies have shown higher complication rates for obese patients, such as increased hospital :stay, wound infections and prolonged mechanical ventilation.
• The patient should be asked about his exercise capacity, patients with unlimited exercise tolerance, who can walk two blocks on level ground without symptoms, generally :have low risk of postoperative complications.
• The patient should be asked when did he last eat or drink at the day of surgery.
• The patient should be asked if he smokes cigarettes, How many packs per day and for How many years.
• The patient should be asked if he drinks alcohol.There is increased risk for postoperative complications in Patients who misuse alcohol on a regular basis.

Preoperative laboratory testing

The American Society of Anesthesiologists recommends against routine preoperative laboratory testing in the absence of clinical indications.

Recommendations for Perioperative Cardiac Assessment

• Class I

1. Patients who have a need for emergency noncardiac surgery should proceed to the operating room and continue perioperative surveillance and postoperative risk stratification and risk factor management. ‘’(Level of Evidence: C)’’ 2. Patients with active cardiac conditions* should be evaluated and treated per ACC/AHA guidelines and, if appropriate, consider proceeding to the operating room. ‘’(Level of Evidence: B)’’ 3. Patients undergoing low risk surgery are recommended to proceed to planned surgery.† ‘’(Level of Evidence: B)’’ 4. Patients with poor (less than 4 METs) or unknown functional capacity and no clinical risk factors should proceed with planned surgery.† ‘’(Level of Evidence: B)’’

• Class IIa

1. It is probably recommended that patients with functional capacity greater than or equal to 4 METs without symptoms‡ proceed to planned surgery.§ ‘’(Level of Evidence: B)’’ 2. It is probably recommended that patients with poor (less than 4 METs) or unknown functional capacity and 3 or more clinical risk factors who are scheduled for vascular surgery consider testing if it will change management.¶ ‘’(Level of Evidence: B)’’ 3. It is probably recommended that patients with poor (less than 4 METs) or unknown functional capacity and 3 or more clinical risk factors who are scheduled for intermediate risk surgery proceed with planned surgery with heart rate control.¶ ‘’(Level of Evidence: B)’’ 4. It is probably recommended that patients with poor (less than 4 METs) or unknown functional capacity and 1 or 2 clinical risk factors who are scheduled for vascular or intermediate risk surgery proceed with planned surgery with heart rate control.¶ ‘’(Level of Evidence: B)’’ Class IIb 1. Noninvasive testing might be considered if it will change management for patients with poor (less than 4 METs) or unknown functional capacity and 3 or more clinical risk factors who are scheduled for intermediate risk surgery. ‘’(Level of Evidence: B)’’ 2. Noninvasive testing might be considered if it will change management for patients with poor (less than 4 METs) or unknown functional capacity and 1 or 2 clinical risk factors who are scheduled for vascular or intermediate risk surgery. ‘’(Level of Evidence: B)’’

§Noninvasive testing may be considered before surgery in specific patients with risk factors if it will change management.

Clinical risk factors include ischemic heart disease, compensated or

prior heart failure, diabetes mellitus, renal insufficiency, and cerebrovascular disease. ¶Consider perioperative beta blockade (see Table 12) for populations in which this has been shown to reduce cardiac morbidity/mortality.

Cardiac Risk Stratification for Noncardiac Surgical Procedures

High (Reported cardiac risk often greater than 5%)

• Emergent major operations, particularly in the elderly
• Aortic and other major vascular surgery
• Peripheral vascular surgery
• Anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss

Intermediate (Reported cardiac risk generally less than 5%)

• Carotid endarterectomy
• Head and neck surgery
• Intraperitoneal and intrathoracic surgery
• Orthopedic surgery
• Prostate surgery

Low (Reported cardiac risk generally less than 1%)

• Endoscopic procedures
• Superficial procedure
• Cataract surgery
• Breast surgery

Estimated Energy Requirements for Various Activities

1 MET Can you take care of yourself? 4 METs Climb a flight of stairs or walk up a hill? Eat, dress, or use the toilet? Walk on level ground at 4 mph or 6.4 km per h? Walk indoors around the house? Run a short distance? Walk a block or two on level ground at 2 to 3 mph or 3.2 to 4.8 km per h? Do heavy work around the house like scrubbing floors or lifting or moving heavy furniture? Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football? 4 METs Do light work around the house like dusting or washing dishes? Greater than 10 METs Participate in strenuous sports like swimming, singles tennis, football, basketball, or skiing? MET indicates metabolic equivalent.Adapted from the Duke Activity Status Index and AHA Exercise Standards.

Stepwise approach to preoperative cardiac assessment

Sources

http://www.askdrwiki.com/mediawiki/index.php?title=Preoperative_Clearance

http://www.asahq.org/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2146059/

http://www.ccspublishing.com/journals3a/Preoperative_Medical_Evaluation.htm

http://www.uptodate.com/contents/preoperative-medical-evaluation-of-the-healthy-patient?source=preview&anchor=H4&selectedTitle=2~150#H4

http://circ.ahajournals.org/content/116/17/e418.full.pdf+html

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