Preoperative Examination

Aka: Preoperative Examination, Perioperative Evaluation, Preoperative Examination in Adults

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II. History: Surgery-specific clearance questions for Adults

  1. Chest Pain
  2. Lower Extremity Edema
  3. Dyspnea
  4. Claudication
  5. Wheezing
  6. Exercise tolerance (ability to perform 4 METS of Exercise)
  7. Obstructive Sleep Apnea symptoms (loud snoring, gasping, Choking)
  8. Chronic Cough
  9. Upper respiratory symptoms in the last 2 weeks
  10. Bleeding Disorders (personal or Family History)
    1. See HEMSTOP Preoperative Hemostatic Assessment Questionnaire
  11. Blood thinner use (e.g. Aspirin, NSAIDS, Warfarin)
  12. Anemia History (or took Iron Supplementation)
  13. Anesthesia problems (personal or Family History)
  14. Pregnancy risk

III. History: Documentation Components

  1. Surgery Indication
  2. Medication Allergies
  3. Problem List
  4. Prior Surgeries or Trauma
  5. Medications including Herbals and supplements
  6. Tobacco use, Alcohol use and Ilicit Drug use

IV. Exam

  1. Vital Signs
    1. Blood Pressure, Heart Rate and Respiratory Rate
    2. Weight, height an Body Mass Index
  2. Cardiopulmonary Exam (minimum)
    1. Heart Exam
    2. Lung Exam
  3. Focus areas
    1. Evaluate any positive answers to surgery-specific clearance questions
    2. Evaluate comorbid condition specific examination

V. Labs: Preoperative

  1. History, physical and surgical procedure risk directs lab screening
    1. Additional labs are required for high risk procedures (e.g. Major Spine Surgery, Roux-en-Y gastric bypass)
    2. No ekg needed for routine Cataract surgery
  2. Otherwise healthy patient for a non-high risk procedure
    1. No routine laboratory testing indicated
    2. Consider a Pregnancy Test in all fertile women
  3. Hemoglobin indications
    1. Anemia History
    2. Blood loss anticipated with procedure
      1. Tonsillectomy
      2. Major intraperitoneal surgery
      3. Vascular surgery
      4. Major Spine Surgery
    3. Consider in chronic conditions prone to Anemia
      1. Chronic Kidney Disease
      2. Chronic Liver Disease
  4. Serum Potassium indications
    1. Diuretics (e.g. Furosemide, Hydroclorothiazide, Chlorthalidone)
    2. ACE Inhibitor or ARB (e.g. Lisinopril, Losartan)
    3. Digoxin
    4. Hypertension
    5. Chronic Kidney Disease
  5. Serum Creatinine indications
    1. Chronic Kidney Disease
    2. Diabetes Mellitus
    3. Hypertension
    4. Congestive Heart Failure
  6. Coagulation study indications (ProTime/INR and PTT)
    1. Coagulopathy history
    2. Anticoagulant use or anticipated use post-surgery
  7. Chest XRay indications
    1. Change in cardiopulmonary status
    2. Consider in patients at higher risk of pulmonary complications in which Chest XRay findings could modify management
      1. Congestive Heart Failure
      2. Chronic Obstructive Pulmonary Disease
      3. Emergency Procedure
      4. Prolonged surgery anticipated
  8. Pregnancy Test indications
    1. Child bearing age and
    2. History suggests pregnancy or uncertain status
  9. Urinalysis
    1. Symptoms of Urinary Tract Infection or
    2. Anticipated surgery with implantation of foreign material (e.g. joint replacement, Heart Valve Replacement)
  10. Electrocardiogram (EKG)
    1. See Preoperative Cardiovascular Evaluation for indications and interpretation

VI. Evaluation: Additional risk assessment as indicated

  1. Malnutrition
    1. Associated with delayed Wound Healing and Surgical Site Infection risk
    2. Consider checking Lab Markers of Malnutrition
  2. Surgical Site Infection
    1. Risk factors
      1. Tobacco Abuse
      2. Diabetes Mellitus
      3. Obesity
      4. Malnutrition
      5. Chronic skin disorders (e.g. Eczema)
    2. Prevention measures
      1. Patients should not shave or remove hair at or near the surgical site
      2. Consider giving patient a 2% Chlorhexidine cloth to clean surgical site (especially prior to total joint procedure)

VII. Contraindications: Surgeries where routine guidelines do not apply

  1. Emergency surgery
    1. High risk emergent condition for which survival is unlikely without surgery
    2. Medical management is directed toward post-operative risk reduction
  2. High Risk Surgery (including thoracic surgery and major vascular surgery)
    1. Consultation with surgeon and other specialists as needed to reduce perioperative risk

VIII. Protocol: Cardiovascular Risk Assessment

  1. See Preoperative Cardiovascular Evaluation
  2. See ACC-AHA Preoperative Cardiac Risk Assessment
  3. No cardiac testing needed if
    1. No acute cardiovascular disease and able to perform 4 METS of Exercise without symptoms
    2. Coronary revascularization in last 6 months to 5 years and asymptomatic, stable (discuss with cardiologist)
    3. Normal coronary evaluation in the last 2 years without intervening symptoms
  4. Additional evaluation needed if criteria above not met
    1. See ACC-AHA Preoperative Cardiac Risk Assessment
    2. High risk patient identification tools
      1. Eagle's Cardiac Risk Assessment
      2. Revised Cardiac Risk Index
      3. Detsky's Modified Cardiac Risk Index

IX. Protocol: Perioperative Medications and risk reduction

  1. General medication and NPO guidelines
    1. See Preoperative Guidelines for Medications Prior to Surgery
    2. Perioperative NPO Guidelines
    3. Medications to Avoid Prior to Surgery
  2. Cardiovascular Risk Reduction
    1. See Medical Management of Perioperative Cardiovascular Risk
    2. Antiplatelet Therapy for Vascular Disease
    3. Perioperative Beta Blocker
  3. Complication prevention
    1. Deep Vein Thrombosis Prevention
    2. Endocarditis Prophylaxis
    3. Surgical Antibiotic Prophylaxis
    4. Postoperative Nausea and Vomiting Prevention
  4. Disease Specific Management
    1. Preoperative Evaluation in Kidney Disease
    2. Perioperative Diabetes Management
    3. Preoperative Respiratory Risk Modification
    4. Perioperative Anticoagulation
    5. Perioperative Corticosteroid

X. Management: Instructions for patients prior to surgery

  1. Bring CPAP machine to surgery
  2. Patients must have responsible adult to transport them home and observe for 24 hours following general Anesthesia or Conscious Sedation
  3. Review perioperative NPO and medication guidelines
    1. Perioperative NPO Guidelines
    2. Medications to Avoid Prior to Surgery
    3. Medications that are not contraindicated perioperatively may be taken with water on the morning of surgery

XI. Resources

  1. Surgical Risk Calculator (ACS NSQIP)
    1. https://riskcalculator.facs.org/RiskCalculator/

XII. References

  1. Danielson (2012) ICSI: Preoperative Evaluation
    1. http://bit.ly.Preop0712
  2. Dummer (2009) Perioperative Guideline Review
  3. (2012) Anesthesiology 116:522-38 [PubMed]
  4. Feely (2013) Am Fam Physician 87(6): 414-8 [PubMed]

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