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Preoperative Evaluation Before Noncardiac
Preoperative Evaluation Before Noncardiac
Abstract
The medical complexity of surgical patients is increasing and medical specialties are frequently asked
to assist with the perioperative management surgical patients. Effective pre-anesthetic medical eval-
uations are a valuable tool in providing high-value, patient-centered surgical care and should sys-
tematically address risk assessment and identify areas for risk modification. This review outlines a
structured approach to the pre-anesthetic medical evaluation, focusing on the asymptomatic patient. It
discusses the evidence supporting the use of perioperative risk calculation tools and focused preop-
erative testing. We also introduce important key topics that will be explored in greater detail in up-
coming reviews in this series.
ª 2019 Mayo Foundation for Medical Education and Research n Mayo Clin Proc. 2019;nn(n):1-16
T
promotes free water retention and the pro-
Division of General Inter-
view articles on perioperative medi- duction of concentrated urine) and renin/ nal Medicine, Rochester,
cal evaluation and management. We aldosterone (which promotes sodium and MN.
review perioperative physiology and intro- water reabsorption). The inflammatory
duce our approach to a pre-anesthetic medi- response to surgery is predominantly driven
cal evaluation, focusing on the asymptomatic by the release of cytokines (interleukin-1,
patient. Subsequent articles will discuss interlukin-6, and tumor necrosis factor-a)
specific topics relevant to perioperative man- from the leukocytes, fibroblasts, and endo-
agement of the surgical patient. thelial cells from the site of the injured tis-
sue. These cytokines initiate a local
THE SURGICAL STRESS RESPONSE AND response, but also initiate a more systemic
THE PHYSIOLOGY OF ANESTHESIA acute-phase response with the production
Understanding the physiologic changes due of acute-phase proteins from the liver. The
to surgical stress and anesthesia are neces- magnitude of the surgical stress response is
sary for perioperative risk assessment and proportional to the degree of surgical injury.
management. The surgical stress response Its duration also varies; the effect of ADH
is activated by afferent input to the hypothal- lasts for 3 to 5 days postoperatively, whereas
amus from the site of tissue injury, which the effects of cytokines last 48 to 72 hours.1
results in endocrine, metabolic, and inflam- Anesthetics contribute to many perioper-
matory responses.1,2 The endocrine stress ative physiologic changes. Two major classes
response includes increases in levels of of anesthesia are available: general and neu-
cortisol, adrenocorticotropic hormone, raxial anesthesia. Multiple factors contribute
growth hormone, catecholamines, renin, to selecting the most appropriate anesthetic,
and antidiuretic hormone (ADH). Metabolic and this choice is best left the anesthesiolo-
changes such as catabolism of carbohydrates, gist. General anesthesia (GA) is comprised
fat, and protein provide increased energy of a triad of hypnosis, analgesia, and muscle
needed for the production of glucose and relaxation.3 During the induction phase, an
acute-phase proteins. Salt and water meta- intravenous combination of a sedative-
bolism is influenced by ADH (which hypnotic (such as propofol, etomidate, or
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PREOPERATIVE EVALUATION BEFORE NONCARDIAC SURGERY
hemodynamic effects, among other vari- may improve this calibration, although the
ables.10 An evaluation of surgery-specific variables and outcomes are limited to only
risk is formally included in American, Euro- those collected by NSQIP. This can lead to
pean, and Canadian guidelines for preopera- differences in the outcomes predicted by
tive cardiac evaluation.7-9 Other societies different calculators, complicating direct
recommend similar approaches for other or- comparisons between calculators.
gan systems.14-17 Table 1 outlines several commonly used
The risk of major adverse cardiac events risk assessment tools categorized by organ
was historically separated into low- (<1%), system. There are no prospective trials
intermediate- (1% to 5%) and high- (>5%) directly comparing perioperative risk assess-
risk categories.18 More recent guidelines ment tools, but the strength and weaknesses
recommend a binary approach, using low have been shown in observational studies.
risk (<1%) and elevated risk (1%) to better Understanding the strengths and limitations
integrate with the clinical decision-making of the tools preferred at one’s practice loca-
process.8 Low-risk procedures, such as cata- tion is crucial to effective use.
ract or dermatologic surgeries, have fewer
hemodynamic shifts and a smaller surgical COMBINED RISK ASSESSMENT
stress response.8 We recommend assessing risk by organ sys-
tem, and outline a structured approach
Patient-Specific Risk below. Surgical urgency, surgical risk, and
Patient-specific risk is attributable to medical patient-specific risk factors are necessary in-
comorbidities that impact the overall risk of puts for clinical decision algorithms and so-
a surgical procedure. The history and phys- ciety guidelines. The combined medical and
ical exam are key components in identifying surgical risk for cardiac complications, pul-
these risk factors. This assessment should monary complications, venous thromboem-
build on the procedure-specific risk; the bolism, postoperative nausea, vomiting, and
preferred risk assessment tools incorporate delirium should be assessed on all pa-
both patient and procedural elements when tients.8,14-17 Additional risks should be
possible. A limitation of many risk assess- assessed on an individualized basis.
ment tools is the assumption that patients
are medically stable and are therefore not ac- Cardiac
curate in patients with acute or progressive The 2014 ACC/AHA guidelines for perioper-
symptoms.19 When these symptoms are ative cardiac evaluation created an easy-to-
identified, they should be evaluated as would follow algorithm to identify patients for
be done in a non-perioperative setting.8 whom stress testing can be considered.8
Perioperative risk assessment tools have Key decisions are based on identifying pa-
several additional limitations. They are tients with acute coronary syndrome,
derived from populations where high-risk elevated perioperative risk of major adverse
conditions with low prevalence such as pul- cardiac events based on a validated risk
monary hypertension and cirrhosis are often assessment (see Table 1), and poor func-
not accounted for in the models, underesti- tional capacity (<4 Measurement of Exercise
mating the risk in affected patients. There Tolerance Before Surgery [METS]). The Ca-
is also the possibility that the absolute risk nadian Cardiovascular Society recommends
estimates may not be accurate. For example, formally evaluating only patients with
the validation and derivation cohorts used to known cardiovascular disease or aged 45
construct the Revised Cardiac Risk Index years or older who are undergoing surgery
showed significant differences in cardiovas- requiring at least an overnight hospital
cular complication rates, particularly with stay. They recommend against stress testing
scores greater than 1.19 The use of large da- and prefer postoperative troponin moni-
tabases such as the National Surgery Quality toring guided by B-naturetic peptide levels
Improvement Program (NSQIP) database over functional capacity assessment.7 These
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MAYO CLINIC PROCEEDINGS
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PREOPERATIVE EVALUATION BEFORE NONCARDIAC SURGERY
TABLE 1. Continued
Tool Outcomes Advantages Limitations
Geriatric risk
calculators, continued
Frailty score28 30-day surgical complications, Components validated in Specific equipment required, time-
length of stay, and discharge perioperative and general consuming
disposition populations
Modified frailty Death, surgical complications, Simple to calculate Not validated in a clinical setting
index29 unplanned 30 day readmission due to NSQIP changes
Mini-Cog30,31 Dementia risk Simple, assesses multiple cognitive
domain, abnormal test predicts
complications
Hepatic risk calculators
MELD32 Death Higher scores correlate with worse Most studies done with older
outcomes (>10) versions of MELD equations
than what is used for transplant
Child-Pugh33 Death Higher scores correlate with worse Performance similar to MELD,
outcomes (>7) which is more widely used for
transplant
Postoperative nausea/
vomiting risk calculators
Apfel score34 Postoperative nausea and vomiting Simple, can guide intervention Moderate predictive power
Koivuranta score35 Postoperative nausea and vomiting Simple, prospectively developed Moderate predictive power
Other risk calculators
CAGE36 Alcohol use disorder Score >2 increases risk of delirium Prospective interventional studies
not available
AUDIT-C37 Alcohol use disorder Higher scores (9-12) associated Prospective interventional studies
with increased complication not available
rates
Duke Activity Status Functional status in METs Incorporates common household Relies on patient recall, decision
Index38 activities thresholds not established
a
ACCP ¼ American College of Clinical Pharmacy; ACS ¼ American College of Surgeons; ARISCAT ¼ Assess Respiratory Risk in Surgical Patients in Catalonia; AUDIT-C ¼
Alcohol Use Disorders Identification Test; MELD ¼ Model for End-stage Liver Disease; MET ¼ metabolic equivalent; MICA ¼ Myocardial Infarction and Cardiac Arrest;
NSQIP ¼ National Surgical Quality Improvement Project; OSA ¼ obstructive sleep apnea; VTE ¼ venous thromboembolism.
capacity is less than 4 METs, pharmaco- surgery are available from the American Col-
logic stress testing is reasonable if the re- lege of Chest Physicians; these guidelines
sults would affect management.8 should be followed over more generalized
The ACC/AHA algorithm does not tools.14 Bleeding risk assessment includes
include noncoronary cardiac conditions, the rate of bleeding inherent to the proced-
but the guidelines do recommend patients ure, the consequences of bleeding (such as
be evaluated if there is clinical evidence of the potentially devastating consequences in
heart failure, valvular heart disease, neurosurgical or reconstructive procedures)
arrhythmia, or other cardiac disorders. Pa- and patient factors such as medications or
tients with established cardiovascular disease comorbidities. The risk of clotting should
also require additional considerations. Those be balanced with the risk of bleeding to
with a history of myocardial infarction or determine the type and duration of prophy-
stroke within the past year deserve careful laxis recommended.
review due to a variety of factors, including
antiplatelet medications and risk of subse- Delirium
quent events.40,41 Delirium is a major contributor to postoper-
ative morbidity and mortality in elderly pa-
Pulmonary tients. Delirium risk should be assessed in
Pulmonary complications contribute to peri- all patients, with special attention to those
operative morbidity and mortality in similar with known or suspected preoperative
magnitude to cardiac complications.15 Pul- cognitive dysfunction.16 A mini-cog score
monary complication rates are higher in up- of 2 or less is associated with an increased
per abdominal, thoracic, and head and neck risk of delirium.31 Assessing baseline cogni-
surgeries due to their impacts on respiratory tion, identifying surrogate decision makers,
mechanics.42,43 Patients should undergo a documenting risk factors, and identifying al-
clinical assessment for new or progressive ternatives to provoking medications in high-
pulmonary disorders, including the impact risk patients are recommended.16
on functional status. This includes assessing
for obstructive sleep apnea (OSA) and hypo- Postoperative Nausea and Vomiting
ventilation syndromes using a validated Postoperative nausea and vomiting is a com-
screening instrument.17,24,44 Patients with mon complication that affects patient com-
symptoms or exam findings suggestive of fort, risk of pulmonary complications, and
function-limiting pulmonary disease should resource use.45 Multiple risk factors have
be evaluated if the surgical urgency permits. been identified, and several models to pre-
The calculators in Table 1 provide risk esti- dict symptoms within the first 24 hours
mates based on surgical and patient factors, have been published (see Table 1). Overall
but do not predict the risk of OSA. performance of these models is similar.46
approaches are not readily available or opti- improved outcomes, and patient satisfac-
mization is desired. tion.17 Table 2 summarizes our suggested
approach.
PREOPERATIVE HISTORY AND PHYSICAL The preoperative history should assess
EXAMINATION functional capacity in metabolic equivalents
The goal of the preoperative history and (METs), including whether the patient is
physical examination is to identify elements able to meet 4 METs regularly and without
needed for preoperative risk assessment significant symptoms. Examples of 4 METs
and reduction, anesthetic management, and of activity include walking on a flat surface
optimization of medical comorbidities. A at a 4-mph pace, walking up a hill or flight
thorough medical, surgical, family, and so- of stairs without stopping or performing
cial history should be obtained. It is also heavy housework such as vacuuming. Pa-
important to document the severity and tients may not accurately self-report METs.
stability of chronic medical conditions. Ex- A large prospective cohort study recently
pected benefits include the safety of periop- compared preoperative subjective assess-
erative care, optimal resource use, ment of METs with other preoperative
markers of fitness, including cardiopulmo- defined by NSQIP. This classifies the patient
nary exercise testing, the Duke Activity Sta- as independent, partially dependent, or
tus Index (DASI) questionnaire, and serum dependent based on the level of assistance
N-terminal pro-B-type natriuretic peptide needed from another person or device to
(NT pro-BNP).39 Preoperative subjective accomplish activities of daily living.10
assessment of METS was only approximately
20% sensitive for identifying patients who PREOPERATIVE TESTING
were unable to achieve 4 METs during car- Thoughtful consideration to what testing is
diopulmonary exercise testing. However, indicated ensures safe, cost-effective care.
the DASI questionnaire was positively corre- Preoperative testing is generally limited to
lated to peak oxygen consumption and nega- those things that have a high likelihood to
tively correlated with NT pro-BNP change management. For most patients un-
concentrations, suggesting the DASI may dergoing surgery, minimal testing is indi-
be superior to subjective assessment. This cated. This approach reduces the impact of
study has prompted us to begin incorpo- false-positive testing and prevents unneces-
rating the DASI into our practice. sary delays for surgeries. Subsequent reviews
Several risk calculators require the pa- in this series address disease-specific man-
tient’s preoperative functional status as agement, so we focus on the management
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PREOPERATIVE EVALUATION BEFORE NONCARDIAC SURGERY
Cardiac Risk Index and Gupta myocardial recovery from malnutrition. In addition,
infarction or cardiac arrest calculator use other conditions such a renal disease and he-
creatinine as one of the risk factors. Specifics patic disease can affect albumin levels. Preal-
regarding management of patients with kid- bumin has a half-life of approximately 2 days
ney disease will be discussed in detail in a but it can be difficult to interpret in the pres-
subsequent review. Routine electrolytes are ence of inflammation, renal disease, and he-
not indicated in the asymptomatic patient. patic disease. Transferrin has a half-life of
The incidence of asymptomatic abnormal- approximately 10 days. It also represents
ities is very low.49 Situations that would the iron status of a patient and therefore
require electrolyte analysis should be easily must be interpreted in conjunction with
predictable from a good history, that is, use iron levels (ie, a low transferrin in the setting
of diuretics for hypertension. of a low serum iron is more indicative of iron
Routine fasting glucose levels are deficiency than protein malnutrition).
also not recommended in asymptomatic
populations. A meta-analysis studying the INFECTION
association between hemoglobin A1c levels Routine urinalysis and culture to screen for
in non-diabetics and surgical complications asymptomatic bacteriuria is not recommen-
did not show any association except in ded. There does not appear to be any signif-
vascular and orthopedic surgeries.52 For pa- icant difference in wound infections for
tients undergoing these types of surgeries, those who had or did not have urinalysis
the authors believed it was reasonable to before most surgeries, including orthopedic
use hemoglobin A1c as screening tool. Pa- surgeries.56,57 Exceptions to this would be
tients who have diabetes should have hemo- high-risk surgeries, such as urologic and gy-
globin A1c levels to monitor the necological surgeries.58
management of their diabetes before surgery. Methicillin-resistant staphylococcus
Routine liver enzyme tests are not rec- aureus (MRSA) infections are a risk to the
ommended in asymptomatic individuals. hospitalized patient and may represent an
Significant abnormalities are uncommon53 even greater risk to the surgical patient.
and analysis of the NSQIP database showed Practices regarding MRSA screening vary
no risk difference between patients who widely. A meta-analysis from 2010
had preoperative liver testing and those concluded that evidence is currently incon-
who did not.54 Patients with liver disease clusive to recommend routine preoperative
should have laboratory studies performed screening for MRSA colonization.59
so that either a Model for End-stage Liver
Disease (MELD) score or a Child-Pugh score PREGNANCY
can be calculated (creatinine, bilirubin, PT, Pregnancy cannot be excluded by history
and albumin). alone and knowing someone is pregnant
may change the surgical plan. Pregnancy
NUTRITION testing in women of child-bearing age is rec-
Routinely obtaining albumin, prealbumin, ommended by the American Society of
and transferrin levels is not recommended Anesthesiologists.17
for asymptomatic patients, with the possible
exception of geriatric patients.16 These are
SPECIAL POPULATIONS
reasonable tests if there is concern for nutri-
tional status based on history, physical exam Geriatric
finding, or underlying medical conditions. Geriatric patients have a higher rate of med-
Low albumin levels (<2.2 g/dL) suggest ical comorbidities including cardiovascular
malnutrition and correlate with poor surgi- disease, cerebrovascular disease, chronic kid-
cal outcomes.55 However, albumin has a ney disease, hypertension, and diabetes.16
half-life of approximately 20 days and may Management of these conditions does not
not reflect recent poor nutrition or recent differ from the nongeriatric population.
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PREOPERATIVE EVALUATION BEFORE NONCARDIAC SURGERY
Issues specific to the geriatric population dysfunction, coronary artery disease, coagul-
include cognitive deficits and delirium, opathy, thrombocytopenia, neutropenia,
malnutrition, frailty, and falls. Current substance use disorders, and infection/colo-
guidelines recommend screening for cogni- nization with MRSA.66 Although some
tive deficits which are a risk factor for post- studies have noted a slight increase in
operative delirium and a history of falls.60 morbidity and mortality in HIV patients
Geriatric patients should be assessed for with either high viral loads or low CD4
frailty and malnutrition using standard counts, organ dysfunction and nutritional
assessment tools (see Table 1). Recent status are superior risk predictors.67,68 Opti-
studies suggest that addressing malnutrition mization of antiretroviral therapy (ART)
and frailty preoperatively with a program of before elective surgery is recommended,
“prehabilitation” improves postoperative and pharmacy oversight for antiretroviral
outcomes.61 In the case of urgent surgery, drug interaction checking is recommended.
increased attention to postoperative rehabil- Clinicians should continue ART in the peri-
itation and nutrition has also been shown operative period with as little interruption as
to be beneficial.60 Patient’s wishes regarding possible. When ART interruption is neces-
advanced directives should be noted, partic- sary, all components of the regimen should
ularly regarding the issue of intraoperative be stopped simultaneously, and clinicians
resuscitation. The Beers criteria should be should consult with a provider who has
used when prescribing medications experience in management of ART.66 Pa-
postoperatively.62 tients who require prophylaxis for Pneumo-
cystis jirovecii and are unable to receive
Pregnancy oral medications for more than 1 week can
The most common nonobstetric conditions receive trimethoprim/sulfamethoxazole
requiring surgery during pregnancy are intravenously or pentamidine intravenously
appendicitis, biliary disease, ovarian torsion or by inhalation.69 Patients with a history
or neoplasm, and trauma. The pre- of P. jirovecii are at increased risk of sponta-
anesthetic medical evaluation should include neous pneumothorax, which could manifest
an obstetrician and medications should be as postoperative dyspnea.70
screened for teratogenicity.63 Elective sur-
geries are recommended to be postponed un- Chronic Liver Disease
til after delivery. Time-sensitive surgery is Patients with cirrhosis are at increased risk
recommended to be performed during the for surgical and anesthesia related complica-
second trimester when the risk of sponta- tions.71 The MELD and Child-Pugh scores
neous abortion is lowest.63 Urgent surgery predict postoperative risk in cirrhotic pa-
can generally be performed safely, although tients.72 Patients with a MELD score of less
the risks may be higher than non-pregnant than 10 are at low risk during elective sur-
patients and mechanical effects of late-stage gery, whereas those with a MELD score
pregnancy have perioperative implica- greater than 10 are at elevated risk.73 This
tions.64,65 Delaying urgent surgery is associ- risk increases with an increasing MELD,
ated with higher complication rates, and and special consideration should be given
patients should not be deprived of an indi- to those with MELD scores of 15 or
cated surgery due to pregnancy alone.63 greater.74 Ninety-day postoperative mortality
rates in patients with MELD scores of 15 or
Human Immunodeficiency Virus higher are greater than 50%, and greater
The preoperative evaluation of patients with than 85% for patients with MELD scores
human immunodeficiency virus (HIV) is over 25.32
similar to that of patients without HIV, Patients with nonalcoholic steatohepati-
with special attention towards conditions tis are at increased risk for coronary disease
that are more prevalent in patients with due to the likelihood of significant dyslipide-
HIV.66 These include hepatic and renal mia.75 Patients with hemochromatosis
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MAYO CLINIC PROCEEDINGS
should be considered for screening for car- possibility of these conditions being
diomyopathy.72 Patients with ascites are at undiagnosed.
increased risk for wound dehiscence and Class 2 and 3 obesity (BMI, 35 kg/m2)
incisional hernia; these patients should be even in otherwise healthy patients, is an in-
treated with diuretics and sodium restriction dependent risk factor for specific adverse
to reduce the ascites burden preoperatively if perioperative outcomes including pneu-
possible.72 Hepatic encephalopathy can be monia, respiratory failure, and postoperative
brought on or aggravated by narcotic- wound infections.79 The perioperative man-
induced constipation and the use of benzodi- agement of comorbid medical conditions
azepine medications; the use of these drugs does not differ in the obese versus nonobese
should be minimized when possible.71 patient.
require parenteral antihypertensive ther- Smoking and substance use disorders in-
apy.82 Upper respiratory infection has been crease perioperative risk directly through ef-
associated with an increased risk in minor fects from the substances themselves and
pulmonary complications in children, but indirectly through an increased risk of
there is no established major morbidity in comorbidities such as coronary artery dis-
adults.83 ease.84 Smoking cessation can have benefits
Mayo Clin Proc. n XXX 2019;nn(n):1-16 n https://doi.org/10.1016/j.mayocp.2019.04.029 13
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MAYO CLINIC PROCEEDINGS
within as little as 2 weeks, although the Individual reprints of this article and a bound reprint of
largest benefit is seen after at least 8 weeks.85 the entire Thematic Review on Perioperative Medicine will
be available for purchase from our website www.
Patients undergoing elective or time- mayoclinicproceedings.org.
sensitive surgeries should be referred for
substance use counseling. The Thematic Review Series on Perioperative Medicine
will continue in an upcoming issue.
Preoperative anemia is associated with a
variety of complications.86 Some studies
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