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 looking at 30-day mortality in the United States showed a rate of 1.32%. This rate varies by type of procedure and varies by country. 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.
    • 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 (1).
  • Clinical risk factors (1): 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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