Description

• Preoperative medical evaluation involves assessing risks specific to the patient, assessment of the risk of the surgery itself, assessing functional status of the patient, consideration regarding medication management, and evaluation for any preoperative testing.
• Following the above assessment, the examiner formulates recommendations for the surgeon and anesthesiologist. Additional recommendations may be given to the patient as well.

Epidemiology

45% of patients age ≥45 years undergoing surgery have several comorbidities and 25% have atherosclerotic cardiovascular disease (ASCVD). There is an approximate 3% risk of death, myocardial infarction (MI), or stroke for noncardiac surgery. Preoperative patient evaluation and subsequent optimization of perioperative care reduce both postoperative morbidity and mortality.

Risk Factors

Factors influencing risk of adverse surgical outcomes may be divided as follows:

• Patient’s functional capacity (1): Exercise tolerance is one of the most important determinants of cardiac risk:
  • Self-reported exercise tolerance may be a useful predictive tool when assessing risk. Patients with poor functional status (unable to achieve >4 metabolic equivalents (METs) or Duke Activity Status Index (DASI) score >34 have an almost 2-fold greater risk of inpatient cardiovascular (CV) events. The BASEL-PMI study showed 1.63× higher rate of death, MI, acute heart failure (HF), or life-threatening arrhythmias at 30 days in patients with poor functional capacity.
  • Patients who report good exercise tolerance require minimal, if any, additional testing.
• Risk of the surgery: High-risk surgeries (>5% risk) include intrathoracic, intra-abdominal, suprainguinal vascular procedures, and emergency surgeries. Low risk surgeries (<1% risk) are superficial procedures, breast surgery, endoscopic procedures, and most ambulatory surgeries. All others would fall under intermediate risk (1–5%). Urgent and emergent surgeries have higher risk.
• Risks associated with patient medical conditions (2)
  • History of ischemic heart disease, significant valvular heart disease, the presence of decompensated HF or a history of HF, poorly controlled HTN, CVA, diabetes mellitus (especially) requiring insulin, and renal insufficiency (creatinine >2 mg/dL)
  • Bleeding risk/history of bleeding, prior anesthesia complications, uncontrolled asthma/COPD/obstructive sleep apnea (OSA), and immunosuppression may also increase risk.
  • Patients >70 years of age are at higher risk for complications, longer length of stay, and mortality. Assess frailty risk using available calculators for geriatric patients.