Preoperative Evaluation of the Noncardiac Surgical Patient – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

  • Preoperative medical evaluation should determine the presence of established or unrecognized disease or other factors that may increase the risk of perioperative morbidity and mortality in patients undergoing surgery.
  • Specific assessment goals include:
    • Conducting a thorough medical history and physical examination to assess the need for further testing and/or consultation
    • Recommending strategies to reduce risk and optimize patient condition prior to surgery
    • Encouraging patients to optimize their health for possible improvement of both perioperative and long-term outcomes
  • Synonym(s): Preoperative diagnostic workup; Preoperative preparation; Preoperative general health assessment

Epidemiology

Overall patient morbidity and mortality related to surgery is low. Multiple studies have shown an average mortality rate of ∼1% for patients undergoing a full spectrum of surgical procedures. Preoperative patient evaluation and subsequent optimization of perioperative care can reduce both postoperative morbidity and mortality.

Risk Factors

  • Functional capacity (1)[B]: Exercise tolerance is one of the most important determinants of cardiac risk:
    • Self-reported exercise tolerance may be an extremely useful predictive tool when assessing risk. Patients unable to meet a 4 metabolic equivalent (MET) demand (defined in the Diagnosis section) during daily activities have increased perioperative cardiac and long-term risks.
    • Patients who report good exercise tolerance require minimal, if any, additional testing.
  • Level of surgical risk:
    • High: Aortic, major vascular and peripheral vascular surgery
    • Intermediate: Intraperitoneal, intrathoracic, carotid endarterectomy, head/neck, orthopedic, and prostate surgery
    • Low: Endoscopic, superficial, cataract, breast, and ambulatory surgery
  • Clinical risk factors (2)[B]: History of ischemic heart disease, the presence of compensated heart failure or a history of prior congestive heart failure, cerebrovascular disease, diabetes mellitus (DM), and renal insufficiency; these risk factors plus surgical risk can dictate the need for further cardiac testing.
  • Age: Patients >70 years of age are at higher risk for perioperative complications and mortality and have a longer length of stay in the hospital postoperatively. (Likely attributed to increasing medical comorbidities with increasing age.) Age alone should not be a deciding factor in the decision to proceed with surgery (3).

Diagnosis

History

  • Evaluate pertinent medical records and interview the patient. Many institutions provide standard patient questionnaires that screen for preoperative risk factors:
    • History of present illness and treatments
    • Past medical and surgical history
    • Patient and family anesthetic history and associated complications
    • Current medications (including over-the-counter [OTC] medications, vitamins, supplements, and herbals) as well as reasons for use
    • Allergies (including specific reactions)
    • Social history: Tobacco, alcohol, drug use, and cessation
    • Family history: Prior illnesses and surgeries
  • Systems (both history and current status):
    • Cardiovascular: Inquire about exercise capacity:
      • 1 MET: Can take care of self, eat, dress, and use toilet; walk around house indoors; walk a block or 2 on level ground at 2–3 mi/h
      • 4 METs: Can climb flight of stairs or walk up hill, walk on level ground at 4 mi/h, run a short distance, do heavy work around house, participate in moderate recreational activities
      • 10 METs: Can participate in strenuous sports such as swimming, singles tennis, football, basketball, or skiing
    • Note presence of CHF, cardiomyopathy, ischemic heart disease (stable vs unstable), valvular disease, HTN, arrhythmias, murmurs, pericarditis, history of pacemaker or ICD:
      • Rhythm management devices (pacemakers and AICDs) affect the perioperative course. Most importantly, patients need to know their type of device and bring that information with them for the procedure. Typically, the AICD tachyarrhythmia function is disabled during surgery and then restored postoperatively. Ideally the device is interrogated postoperatively to confirm proper function (4).
      • Stents: Patients with coronary stents are maintained on antiplatelet therapy with a thienopyridine such as clopidogrel, frequently in combination with aspirin. Premature discontinuation of antiplatelet therapy markedly increases the risk of acute stent thrombosis, the results of which can be catastrophic. Elective surgery should be delayed and antiplatelet therapy continued for 4–6 weeks after bare metal stent placement, and for at least 12 months after placement of drug-eluting stents. Even after this time period, any perioperative disruption in the patient’s antiplatelet regimen should be discussed with the patient’s cardiologist and surgeon. The risk of perioperative bleeding must be weighed against the risks associated with discontinuation of antiplatelet drugs prior to surgery (5)[B].
    • Pulmonary: Chronic and active disease processes should be addressed: Chronic infections, bronchitis, emphysema, asthma, wheezing, shortness of breath, cough (productive or otherwise):
      • Sleep apnea: Patients with obstructive sleep apnea (OSA) are at increased risk for perioperative adverse events. It follows that preoperative diagnosis of OSA and institution of CPAP therapy should reduce that risk. Unfortunately, at present, the evidence is not clear on this point.
      • Patients with OSA frequently are at increased risk for obesity, coronary disease, hypertension, atrial fibrillation, congestive heart failure, and pulmonary hypertension. Optimizing the management of these comorbidities may be the first important step in the preoperative management of patients with OSA. Often, patients with an existing diagnosis of OSA who use CPAP at night are asked to bring their CPAP machine to the hospital or surgery center when they are admitted for surgery (6)[C].
    • GI: Hepatic disease, gastric ulcer, inflammatory bowel disease, hernias (especially hiatal), significant weight loss, nausea, vomiting, history of postoperative nausea and vomiting:
      • Any symptoms consistent with gastroesophageal reflux disease (GERD) should be optimally treated.
    • Hematologic: Anemia, serious bleeding, clotting problems, blood transfusions, hereditary disorders
    • Renal: Kidney failure, dialysis, infections, stones, changes in bladder function
    • Endocrine: Nocturia, parathyroid, pituitary, adrenal disease, thyroid disease
      • Diabetes: There is evidence that hyperglycemia in the perioperative period is associated with postoperative infection (7)[B].
    • Neurologic/psychiatric: Seizures, stroke, paralysis, tremor, migraine headaches, nerve injury, multiple sclerosis, extremity numbness, psychiatric disorders (anxiety, depression, etc.)
    • Musculoskeletal: Arthritis, lower back pain
    • Reproductive: Possibility of pregnancy in women of child-bearing potential
  • Mouth/upper airway: Dentures, crowns, partials, bridges, teeth (loose, chipped, cracked, capped)

Physical Exam

  • Assess vital signs, including arterial BP bilaterally.
  • Check carotid pulses, auscultate for bruits.
  • Examine lungs by auscultating all lung fields, listening for rales, rhonchi, wheezes, or other sounds indicating disease.
  • Examine cardiovascular system by auscultating heart and noting any irregular rhythms or murmurs. Precordial palpation.
  • Palpate abdomen.
  • Examine airway and mouth for ease of intubation, neck mobility, and size of tongue, and note any lesions or dental deformities.
  • If a regional anesthesia technique is being contemplated, perform a relevant, focused neurologic exam.

Diagnostic Tests & Interpretation

Lab

Initial lab tests

  • Laboratory testing should not be obtained routinely prior to surgery unless indicated (2)[C]. Specific tests should be requested if the evaluator suspects findings from the clinical evaluation that may influence perioperative patient management.
  • Labs performed within the past 4 months prior to evaluation are reliable unless the patient has had an interim change in clinical presentation or is taking medications that require monitoring of plasma level or effect.
  • Complete blood count (CBC) (2)[C]:
    • Hemoglobin: If patient has symptoms of anemia or is undergoing a procedure with major blood loss; extremes of age; liver or kidney disease
    • White blood cell (WBC) count: If symptoms suggest infection or myeloproliferative disorder or the patient is at risk for chemotherapy-induced leukopenia
    • Platelet count: If history of bleeding, myeloproliferative disorder, liver or renal disease, or the patient is at risk for chemotherapy-induced thrombocytopenia
  • Serum chemistries (electrolytes, glucose, renal and liver function tests) (2)[C]: Should be obtained for extremes of age; in known renal insufficiency, CHF, liver dysfunction, or endocrine abnormalities, or the patient is on medications that alter electrolyte levels, such as diuretics
  • Prothrombin time (PT)/partial thromboplastin time (PTT) (2)[C]: If history of a bleeding disorder, chronic liver disease, or malnutrition, or those with recent or chronic antibiotic or anticoagulant use
  • Urinalysis (2)[C]: Routine urinalysis is not recommended preoperatively.
  • Pregnancy test: Controversial; should be considered for all female patients of child-bearing age

Imaging

Initial approach

CXR is not generally indicated (2)[C]. It can be considered in patients with recent upper respiratory tract infection and in those with suspected cardiac or pulmonary disease (because there is a likelihood for unanticipated findings), but these indications are not considered unequivocal.

Diagnostic Procedures/Surgery

  • ECG (2)[C]: There are various recommendations reported in the literature:
    • AHA/ACC recommends that a preoperative ECG be obtained for patients who are to undergo vascular surgery and have at least 1 clinical risk factor, and for patients undergoing intermediate risk procedures who have a history of CHF, PVD, or cerebrovascular disease.
    • ECGs are reasonable in vascular surgery patients with no risk factors and patients having intermediate risk procedures who have 1 clinical risk factor.
    • ECGs are not indicated for asymptomatic patients undergoing low-risk procedures.
  • Further cardiac testing should be considered in patients with poor or unknown functional capacity and 3+ clinical risk factors if the surgery is high risk and testing will change management (e.g., dipyridamole-thallium scan).
  • Pulmonary function tests: Definitive data regarding the efficacy of preoperative testing is lacking. The most important factor is preoperative optimization of patients with COPD or reactive airways disease with indicated use of antibiotics, bronchodilators, and inhaled corticosteroids. Spirometry can help guide therapy. Upper abdominal and thoracic surgery have a higher risk of postoperative pulmonary complications.

Treatment

Medication

  • Reducing cardiac risk:
    • Elective surgery should be delayed or canceled if the patient has any of the following: Unstable coronary syndromes (unstable or severe angina), recent myocardial infarction (<30 days), decompensated heart failure, significant arrhythmias, or severe valvular disease.
    • Active CHF should be treated with diuretics, afterload reduction, and β-adrenergic blockers.
    • Perioperative β-blockade has been shown to reduce mortality and the incidence of perioperative MIs in high-risk patients. Studies conflict, however, in what patients need to be treated, the dosage and timing of treatment, and for what surgeries. Patients chronically on B-blockers need to have them continued in the perioperative period. When B-blockers are discontinued in the perioperative period, 30-day mortality increases. B-blockers are reasonable for vascular surgery patients with at least 1 clinical risk factor (1)[C].
    • Perioperative statin use may have a protective effect on cardiac complications; prior to initiation of therapy, liver function and creatine kinase levels should be assessed.
  • Reducing pulmonary risk:
    • Recommend cigarette cessation for at least 8 weeks prior to elective surgery
    • Patients with asthma should not be wheezing and should have a peak flow of at least 80% of their predicted or personal-best value.
    • Treatment of chronic obstructive pulmonary disease (COPD) and asthma should focus on maximally reducing airflow obstruction and is identical to treatment of nonsurgical patients.
    • Lower respiratory tract infections (bacterial) should be treated with appropriate antibiotic therapy.

References

1. American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, et al. 2009 ACCF/AHA focused update on perioperative beta blockade. J Am Coll Cardiol. 2009;54:2102–28.

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2. American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Practice advisory for preanesthesia evaluation: a report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2002;96:485–96.

3. Carrillo PM, et al. Perioperative risk evaluation. Internet J Anesthesiol. 2004;8(2).

4. American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Cardiac Rhythm Management Devices et al. Practice advisory for the perioperative management of patients with cardiac rhythm management devices: pacemakers and implantable cardioverter-defibrillators: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Cardiac Rhythm Management Devices.Anesthesiology. 2005;103:186–98.

5. Mauermann WJ, et al. Percutaneous coronary interventions and antiplatelet therapy in the perioperative period. Journal of Cardiothoracic and Vascular Anesthesia. 2007;21(3):436–442.

6. Chung SA, Yuan H, Chung F. A Systematic Review of Obstructive Sleep Apnea and Its Implications for Anesthesiologists. Anesthesia and Analgesia2008;107(5):1543.

7. Lipshutz AK, Gropper MA et al. Perioperative glycemic control: an evidence-based review. Anesthesiology. 2009;110:408–21.

Additional Reading

Menke H, Klein A, John KD, et al. Predictive value of ASA classification for the assessment of the perioperative risk. Int Surg. 1993;78:266–70.

Polanczyk CA, Marcantonio E, Goldman L, et al. Impact of age on perioperative complications and length of stay in patients undergoing noncardiac surgery. Ann Intern Med. 2001;134:637–43.

Reilly DF, McNeely MJ, Doerner D, et al. Self-reported exercise tolerance and the risk of serious perioperative complications. Arch Intern Med. 1999;159:2185–92.

See Also (Topic, Algorithm, Electronic Media Element)

Algorithm: Preoperative Evaluation of the Noncardiac Surgical Patient

Codes

ICD9

  • V72.83 Other specified pre-operative examination
  • V72.84 Pre-operative examination, unspecified

Snomed

133898004 preoperative care (regime/therapy)

Clinical Pearls

  • The preoperative evaluation should include medical record evaluation, patient interview, and physical exam.
  • The minimum for the physical exam includes airway, pulmonary, and cardiovascular exams.
  • Functional capacity, the level of surgical risk, and clinical risk factors determine if further cardiac testing is needed.
  • No preoperative tests are routine.
  • Active cardiac conditions should lead to delay or cancellation of nonemergent surgery.

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