Preoperative Evaluation of the Noncardiac Surgical Patient

Preoperative Evaluation of the Noncardiac Surgical Patient is a topic covered in the 5-Minute Clinical Consult.

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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 the following:
    • Conducting a thorough medical history and physical exam 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. One large study of inpatients in the United States showed a 30-day mortality rate of 1.32%. Another study found that perioperative acute myocardial infarction (MI) and death decreased from 2004 to 2013, but the rate of ischemic stroke has increased. Preoperative patient evaluation and subsequent optimization of perioperative care can reduce both postoperative morbidity and mortality.

Risk Factors

  • Functional capacity (1): 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 equivalents (METs) demand (defined in the “Diagnosis” section) during daily activities have increased perioperative cardiac and long-term risks. A study compared physicians’ subjective assessment of functional capacity to objective measures of functional capacity. It found that the subjective assessment tended to misclassify high-risk patients as low risk. Structured questionnaires such as the Duke Activity Status Index had much better prognostic accuracy to assess functional status (2).
    • Patients who report good exercise tolerance require minimal, if any, additional testing.
  • Levels of surgical risk
    • An increased risk for major adverse cardiac events (MACE) is associated with procedures that are intrathoracic, intra-abdominal, or vascular procedures that are suprainguinal in nature.
  • Clinical risk factors: history of ischemic heart disease, the presence of compensated heart failure or a history of prior congestive heart failure (CHF), 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 or not to proceed with surgery.

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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 the following:
    • Conducting a thorough medical history and physical exam 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. One large study of inpatients in the United States showed a 30-day mortality rate of 1.32%. Another study found that perioperative acute myocardial infarction (MI) and death decreased from 2004 to 2013, but the rate of ischemic stroke has increased. Preoperative patient evaluation and subsequent optimization of perioperative care can reduce both postoperative morbidity and mortality.

Risk Factors

  • Functional capacity (1): 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 equivalents (METs) demand (defined in the “Diagnosis” section) during daily activities have increased perioperative cardiac and long-term risks. A study compared physicians’ subjective assessment of functional capacity to objective measures of functional capacity. It found that the subjective assessment tended to misclassify high-risk patients as low risk. Structured questionnaires such as the Duke Activity Status Index had much better prognostic accuracy to assess functional status (2).
    • Patients who report good exercise tolerance require minimal, if any, additional testing.
  • Levels of surgical risk
    • An increased risk for major adverse cardiac events (MACE) is associated with procedures that are intrathoracic, intra-abdominal, or vascular procedures that are suprainguinal in nature.
  • Clinical risk factors: history of ischemic heart disease, the presence of compensated heart failure or a history of prior congestive heart failure (CHF), 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 or not to proceed with surgery.

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