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Preoperative Evaluation For Non-Cardiac Surgery: AK Ghosh
Preoperative Evaluation For Non-Cardiac Surgery: AK Ghosh
Preoperative Evaluation For Non-Cardiac Surgery: AK Ghosh
Abstract
Internists are frequently consulted to perform preoperative risk assessments on patient undergoing non-
cardiac surgery. Physicians need to assess the cardiac risk associated with the surgery, identify the patient’s
unique risk profile, recommend appropriate preoperative testing and make suitable recommendations. By a
focused history-taking, physical examination, and application of current evidence-based guidelines in cardiac
risk assessments, patients at high risk for complications at surgery can be identified and additional work-up
suggested. Effective preoperative recommendation includes an assessment of risk (cardiac and non-cardiac),
recommendations on medication adjustment, thrombo-embolic prophylaxis, and use of perioperative β
blockers. Prompt communication with the surgeon often enhances the quality of medical consultation and
ensures compliance. ©
angiogram) is required in patients with major clinical deficiency, or on anticoagulants). NSAIDs like aspirin
predictors, those with intermediate clinical predictors should be discontinued one week prior to elective
and poor functional capacity (4 METs) or undergoing procedures. Warfarin should be discontinued 5 days
high surgical risk procedures, and in patients with prior to elective procedures. Most surgeries can be
minor clinical predictors and poor functional capacity performed safely at an INR (international normalized
undergoing high risk procedure (Fig. 1). ratio) of < 1.5. Patient with mechanical prosthetic valves
Assessment of Pulmonary risks undergoing surgery should discontinue Warfarin several
days prior to the procedure and managed with low-
Pulmonary complications (pneumonia,
molecular weight heparin (LMWH). LMWH can be
hypoventilation and atelectasis) occur in about one-third
discontinued 12 to 24 hours prior to surgery and
patients postoperatively, and account for 50% of overall
restarted postoperatively along with warfarin when it
mortality 15. Preoperative pulmonary testing is indicated
is considered safe. A hematologist must be involved in
in patients with suspected lung disease, patients with
the care of the care of patients with hereditary or platelet
over 10 pack-year history of smoking, patients with
factor disorders, clotting factors deficiency.
chronic obstructive lung disease (COPD). Forced
expiratory volume in 1 second (FEV1) is probably the Surgical patients at high risk for venous
best indicator of surgical risk. Patients with FEV1 > 2 can thromboembolism (TE) include those who are obese,
safely undergo surgery while patients with FEV1 of < 1 elderly, undergoing prolonged operations or hip surgery,
are at high risk of postoperative pulmonary history of malignancy, previous TEs, hereditary
complication. Chest X-ray is recommended for patients disorders of thrombosis, or use estrogen. These patients
suspected of chronic lung disease, pulmonary require TE prophylaxis with measure such as the use of
tuberculosis and those undergoing thoracic or LMWH, unfractionated heparin, or warfarin, early
abdominal surgery. Arterial blood gas evaluation maybe mobilization and intermittent pneumatic compression
reserved for patients with severe COPD. devices.16
Preoperative precautions to decrease pulmonary risks Endocrine aspects of risk assessment
include smoking cessation, preferably several weeks Common endocrine conditions that impact
prior to surgery, use of bronchodilators and treatment of perioperative risk includes diabetes mellitus, thyroid
chronic bronchitis. Postoperatively, for patients with disorders and secondary adrenal insufficiency due to
chronic lung disease, incentive spirometry, prior corticosteroid use.
bronchodilators, chest physiotherapy and early Patients with poorly controlled diabetes are more
mobilization are encouraged. prone to developing wound infections. Hence, it is
Preoperative Hematologic Risk Assessment desirable to have at least moderate blood sugar control
Patients should be assessed for increased bleeding preoperatively. Patients on oral hypoglycemic agents
risks (use of non-steroidal anti-inflammatory agents, should hold their medication on the morning of surgery.
hereditary or platelet factor disorders, clotting factors Metformin should be held 48 hours prior to surgery and
Chlorpropamide (due to prolonged half-life) should be
308 www.japi.org © JAPI • VOL. 53 • APRIL 2005
held 48-72 hours prior to surgery. On the morning of dialysis 12 hours preoperatively and 12-24 hours
surgery, regular insulin should be held, and one-half postoperatively, to optimize fluid and electrolyte balance.
the dose of NPH insulin must be administered. Routine Elective surgery should be postponed in patients with
autonomic function tests are not indicated severe acute infections.
preoperatively, though patients with autonomic
Role of routine pre-operative laboratory testing
disorders should be carefully monitored in the
intraoperative and postoperative period for Laboratory testing is rarely indicated in patients under
hemodynamic change and hypothermia. Underlying the age of 50 years. For patients over 50 years, minor
cardiovascular disorder may also complicate the abnormality of laboratory tests rarely delays surgery.21
preoperative assessment in diabetic patients. Recent When indicated, specific tests should be planned based
studies on retrospective observation study in patient on the clinical history of the patients. In the past, chest
undergoing cardiac surgery, indicate that patient with X-rays were done on all patients undergoing surgery
higher intraoperative hyperglycemia might have due to the high prevalence of undetected pulmonary
increased complication of atrial fibrillation, cardiac tuberculosis. However, current day indication of chest
arrest, pneumonia , urinary tract infection developing X-ray is limited to patients over 60 years, or those with
with 30 days of cardiac surgery.17 A 20 mg/dl increase known pulmonary symptoms or with cardiac disease.
in mean glucose level was associated with a 30% The current recommendation of routine laboratory
increase in adverse outcome.17 Serum glucose should be testing is summarized in Table 3.
maintained below 150 mg/dl in the postoperative Table 3 : Indications of Routine Pre-operative tests in
period. adults undergoing elective surgical procedures
Patient with hypothyroidism present low surgical risk Tests Indications
and should continue on their regular thyroid
Hematocrit All women, men > 60 yrs, anticipated
replacement dosage. Uncontrolled hypothyroidism may blood loss
result in delayed clearance of anesthetic agents. Patients Electrolytes Patients > 60 yrs, diabetics, renal and
with uncontrolled thyrotoxicosis are at high surgical liver disease, patients on diuretics
risk of thyroid storm, hence elective surgery should be Urinalysis Recommended only for prosthetic joint
postponed for at least 3 months or until the patient in Placement surgeries
euthyroid. In case of emergency surgery in a patient with Protime and partial Patient with liver disease, anti-
thromboplastin time coagulated patients, malignancy,
thyrotoxicosis, pretreatment with propranolol and neurosurgical procedures
propylthiouracil is recommended. Chest radiograph Patients >60 yrs, patients with cardiac
Secondary adrenal insufficiency must be suspected and pulmonary disorders
Electrocardiogram All men older than 40 yrs and women
in patients who have received long-term steroid therapy, over 50 years, all diabetics and patient’s
or those that have received at least 2 weeks of steroids in with history of heart disease
the previous year. These individuals should be covered
with replacement doses of corticosteroids in the pre- and
Management of chronic outpatient medications
peri-operative period.18
Elderly patients account for one-third of all surgeries,
Nutritional Status and Surgical outcome
and half of all emergency procedures. Most elderly
Malnutrition and hypoalbuminemia has been patients have one or more concomitant chronic medical
associated with postoperative morbidity and mortality. disorder and are on numerous medications. Physicians
A decrease of serum albumin from greater 4.6 g/dl to have to be aware of the medication adjustments and
less than 2.1 g/dl was associated with an increase in suggest appropriate medication modifications to avoid
mortality from <1% to 29%, and increase in morbidity perioperative complications. 22 Table 4 outlines the
from 10% to 65%. 19 Patient who are severely appropriate management of commonly prescribed
malnourished (> 15% loss of body weight), might benefit medications.
from preoperative nutritional intervention.20
Preoperative templates and recommendations
Risk assessment of other organ systems
The purpose of preoperative evaluation by internists
Patients with chronic liver disease are at high risk of
includes an assessment of the cardiac and noncardiac
delayed clearance of anesthesia and prolonged
risk factors for surgery, recommendation for appropriate
intubation. These patients require a baseline assessment
testing, assessment of fitness for surgery and
of prothrombin time and partial thromboplastin time
recommendations for perioperative medication such as
assays and need to be monitored for bleeding
â blockers and venous thromboembolism prophylaxis.
complications.
The mnemonic (A to I) could be helpful in summarizing
Patients with renal insufficiency require close the history of a preoperative evaluation. A- allergies, B-
monitoring to prevent hypotension, fluid and electrolyte bleeding tendencies, C- coronary artery disease, CHF,
imbalances and antibiotic nephrotoxicity. Patients with COPD, D- list of drugs, E- endocrine including thyroid
end-stage renal failure undergoing surgery may need
© JAPI • VOL. 53 • APRIL 2005 www.japi.org 309
Table 4 : Medication adjustments and recommendations- Table 5 : Template for preoperative assessment and
prior to elective surgery recommendations
Medication Perioperative modification 1 ) Type of surgery planned: elective, emergency
2 ) History of presenting illness
Antihypertensives Take on the morning of surgery
a ) History of CAD : None, Class I, Class II, Class III,
(exception of diuretics)
Class IV
Digoxin Check digoxin level. Take on morning
b) History of CHF : None, Class I, Class II, Class III,
of surgery
Class IV
HMG CoA reduction Hold prior to surgery. Increase
c) Pulmonary disease : None, COPD, asthma, smoking,
and Gemfibrozil risk of rhabdomyolysis pulmonary tuberculosis
NSAIDs – d) Diabetes mellitus : None, Type I, Type II
Aspirin, NSAIDs Hold 1 week prior to surgery e) Renal disease : None, Yes
Clopidogrel Hold 5 days prior to surgery
f) Functional status : Poor, Moderate, Good
Warfarin Hold 3-5 days prior to surgery
i) Bleeding risk : None, Yes
Oral hypoglycemic agents
j) Prior hepatitis or blood transfusion : Yes, None
Metformin Hold 2 days prior to surgery
Chlorpropamide Hold 2-3 days prior to surgery k) Venous thromboembolism risk : None, Yes
Newer oral Hold on the morning of surgery l) Prior anesthesia complications : Yes, None
hypoglycemic m) History of aspirin use : Yes, None
Insulin- Regular Hold on morning of surgery n) History of recent steroid use : None, Yes
NPH ½ dose on the AM of surgery o) History of alcohol dependence : None, Yes
Bronchodilators Take prior to surgery 3 ) Medication and allergy list
Thyroid replacement Take prior to surgery 4 ) Focused review of systems : prior CABG, cardiac stress
Sedatives Hold on morning of surgery, reassess test (last 2 years)
further use in postoperative period 5 ) Vitals signs and focused examination : BP, Pulse, JVP,
Hypnotics Hold on morning of surgery, reassess carotid bruits, S3, severe aortic stenosis, lung sounds, active
further use in postoperative infection
Estrogen Discontinue prior to surgery 6 ) Impression, Recommendations and Plan :
Herbal medication Discontinue prior to surgery a ) Cardiac risk for noncardiac surgery : Low risk (< 1%),
intermediate risk (< 5%), high risk procedure (> 5%)
b) Patients Clinical risk predictors : None, minor,
status, diabetes mellitus and corticosteroid use, F- family intermediate, major
history of malignant hyperthermia, G- glaucoma, H – c) Results of laboratory test- summarize
hepatitis, HIV and I – infections (Tuberculosis or active d) Fitness for surgery : Yes, No (require additional
infection). Internist should avoid using the term, ‘okay evaluation)
for surgery’. The plans regarding the type and mode of e) If fit for surgery, additional recommendations : β
blockers, DVT prophylaxis, medication adjustments,
anesthesia, and the decision to proceed with surgery is
delirium risk
a shared decision, to be made by the surgeon, the
anesthetist and the patient. CAD- coronary artery disease, CHF- congestive heart failure,
COPD- chronic obstructive pulmonary disease, JVP- jugular
Several hospitals use templates to perform a venous pressure
preoperative evaluation. We have summarized a
template for preoperative assessment in Table 5. High who are likely to benefit from β blockade include those
risk patients requiring additional evaluations, i.e. stress with history of known coronary artery disease (history
testing or coronary angiogram can be identified quite of myocardial infarction, angina, positive exercise stress
easily using this format.6 It is important to note that test) and suspected coronary artery disease (having 2 or
patient is never subjected to coronary angiogram and more of these risk factors, age > 65 yrs, hypertension,
coronary bypass surgeries just to ‘get through the nicotine dependence, diabetes mellitus, cholesterol > 240
surgery.’ These procedures are often indicated mg/dl).11 These patients would benefit from the initiation
independent of the elective surgical procedure. of Atenolol 50 mg on the day of surgery and continued
Additionally, in patients who have undergone coronary up to one week postoperatively, or until discharge. The
artery stenting, surgery is deferred for several months as benefit from the use of â blockade on reduction in cardiac
the risk of postoperative mortality and morbidity is risk has been noted to last for at least 2 years
higher in this group of patients in the months postoperatively.
immediately following the coronary artery stenting Hence, by adhering to structured history taking and
procedure. Often these patients are on Clopidogrel performing a patient focused examination, an efficacious
(Plavix), which can increase the risk of postoperative preoperative evaluations can be performed in a
bleeding. reasonable and timely fashion. Internists can provide
Recent studies have demonstrated that in select valuable assistance to their surgical and anesthesia
patients at high risk for coronary artery disease, use of â colleagues by evaluating and coordinating the care of
blockers can reduce the incidence of preoperative patients scheduled to undergo surgery. The internist
mortality and myocardial infarction by 50%.10 Patients must communicate effectively to their referring
Announcement
CDE-05
3rd National Conference on Cardiology, Diabetology and Electrocardiology, Bhopal
1st and 2nd October 2005
Venue : Hotel Jehan Numa Palace, (MP) Bhopal
For any information please contact : Dr. PC Manoria, Organizing Chairman CDE 05
Mobile : 9827074602; Phone : 0755-2422299 E-mail : pmanoria@rediffmail.com
Conference Secretarial : E-5/103, Arera Colony, Bhopal 462 016.
Announcement
Cardiology Update Edited by Dr. PC Manoria
1. Cardiology Update Vol. 1 : Drugs for Heart and Diabetes
2. Cardiology Update Vol. II : Cardiac Emergencies.
Available on : The National Book Depot. Opp. Wadia Children's Hospital, Parel, Mumbai 400 012.
Contact No. : Tel. 022-2413 1362/2413 2411/2416 5274; Fax No. 022-2413 0877
For any information please contact : Dr. PC Manoria, Contact No. 0755-242229/9827074602