The Preoperative Evaluation

The Medicine Consult Handbook 2011

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1he preop" remalns a common and lmporLanL role for Lhe medlcal consulLanL. 1he medlcal
hlsLory ls Lhe same as any medlcal hlsLory and physlcal (P&), buL Lhere are addlLlonal facLors Lo
conslder.

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1. WhaL ls Lhe surglcal rlsk?
2. WhaL are Lhe paLlenL's rlsk facLors?
3. Pow urgenL ls Lhe surgery?

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1he APA/ACC guldellnes caLegorlze surglcal rlsk lnLo low, lnLermedlaLe, and hlgh rlsk, wlLh
ambulaLory surgery belng low rlsk, and ma[or vascular surgery belng hlgh rlsk. Powever, Lhese
guldellnes do noL llsL Lhe hundreds of Lypes of surgery ln exlsLence, and Lherefore one musL use
cllnlcal [udgmenL Lo esLlmaLe Lhe surglcal rlsk. AddlLlonally, Lhe APA/ACC guldellnes' surglcal rlsk
caLegorles refer Lo Lhe rlsk of cardlovascular compllcaLlons, noL overall morbldlLy or morLallLy.
lacLors Lo Lake lnLo conslderaLlon lnclude:
uuraLlon of general anesLhesla-surgery longer Lhan 8 hours has been assoclaLed wlLh
lncreased rlsk of compllcaLlons
Lmergency surgery-generally consldered hlgher rlsk
8lood loss
LocaLlon and posslble compllcaLlons-e.g. abdomlnal surgery may be more rlsky ln a
paLlenL wlLh clrrhosls
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Cardlovascular rlsk ls well descrlbed ln Lhe APA/ACC guldellnes. Conslder also Lhe rlsk of
perloperaLlve aLrlal flbrlllaLlon. A Lhorough medlcal hlsLory wlll help ldenLlfy paLlenLs aL rlsk for
pulmonary compllcaLlons, or have bleedlng dlaLheses, or hypercoagulable sLaLes, or lncreased rlsk
of dellrlum. 1he secLlons ln Lhls handbook LhaL follow are useful guldes for speclflc condlLlons.
8ecommended ls Lo read ?40@2>A463/540 &267 .90492=23492>;" and %/5B>;40C &267 (66:66B:;9"
for all paLlenLs, and oLher secLlons as perLlnenL.

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CfLen underesLlmaLed, Lhe urgency of surgery ls a crlLlcal parL of Lhe preoperaLlve evaluaLlon. lor
example, a paLlenL wlLh slgnlflcanL cardlovascular rlsk mlghL reasonably undergo sLress LesLlng for a
ma[or elecLlve procedure, buL would llkely forego such LesLlng prlor Lo a necessary, urgenL surgery
for cancer. ln Lhe laLLer case, medlcal managemenL may be preferred, as a poslLlve preoperaLlve
sLress LesL ls unllkely Lo lead Lo coronary surgery or revascularlzaLlon prlor Lo Lhe cancer surgery.

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Cnce Lhese elemenLs are known, Lhe preoperaLlve evaluaLlon, lncludlng recommendaLlons, should
be summarlzed ln a conclse buL Lhorough noLe.

llrsL, sLaLe wheLher Lhe paLlenL ls of accepLable rlsk Lo undergo surgery. As menLloned prevlously,
avold Lhe Lerm clearance"-Lhls Lerm lmplles LhaL noLhlng wlll go wrong. 1here may be
compllcaLlons wlLh !"# surglcal procedure-Lhe key assessmenL ls wheLher Lhe anLlclpaLed beneflLs
ouLwelgh Lhe rlsks.



The Preoperative Evaluation
The Medicine Consult Handbook 2011
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Mr. ____ presenLs for elecLlve LoLal hlp arLhroplasLy. Pe ls an accepLable
candldaLe for Lhls surgery."

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Pe has lncreased cardlovascular rlsk due Lo cllnlcal rlsk facLors of dlabeLes
and a prlor 1lA. Powever, hls exerclse Lolerance ls good and l do noL
recommend any furLher cardlac LesLlng prlor Lo Lhls lnLermedlaLe rlsk
procedure.

Pe has lncreased rlsk of pulmonary compllcaLlons due Lo Lhe presence of
CCu and obsLrucLlve sleep apnea. CCu remalns sLable, and hls CSA ls well
LreaLed wlLh CA.

Pe ls aL rlsk for posLoperaLlve dellrlum."

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aLlenLs are senL Lo Lhe lnLernlsL noL [usL for an assessmenL, buL for recommendaLlons.
8ecommendaLlons should go beyond Lhe APA/ACC guldellnes. Cur role as a medlcal
consulLanL ls also Lo provlde guldance on perloperaLlve medlcaLlon managemenL,
managemenL of chronlc medlcal condlLlons, anLlclpaLe and mlLlgaLe poLenLlal
perloperaLlve compllcaLlons, and recommend approprlaLe prophylacLlc measures.

l recommend Lhe followlng:
1. roceed wlLh surgery wlLhouL furLher cardlac LesLlng.
2. ConLlnue hls beLa-blocker posLoperaLlvely. Pe ls anLlclpaLed Lo be
Laklng oral meds lmmedlaLely posLop, so he may be glven
meLoprolol 30 mg C 8lu, hls home dose, holdlng lf hls S8 ls
<110 or P8 <60, as ofLen paLlenLs are relaLlvely hypoLenslve
lnlLlally posLop.
3. uv1 prophylaxls should be provlded posLop per Lhe 2008 ACC
guldellnes, for hlp replacemenL Lo lnclude low molecular welghL
heparln, fondaparlnux, or warfarln. Cf Lhese opLlons, glven our
lnsLlLuLlonal formulary, l recommend dalLeparln 3000 unlLs
subcuLaneously once dally for aL leasL 10 days.
4. Pls posLoperaLlve paln should be LreaLed, buL psychoacLlve
medlcaLlons should be mlnlmlzed Lo avold dellrlum.
3. osLoperaLlve lncenLlve splromeLry.
6. ConLlnue hls usual LloLroplum lnhaler posLop, and have albuLerol
nebullzers 8n. Should he develop a CCu exacerbaLlon, l would
favor corLlcosLerolds.
7. SLarL a low dose supplemenLal correcLlon algorlLhm wlLh premeal
llspro posLop. 8esLarL meLformln when paLlenL ls eaLlng and renal
funcLlon has been conflrmed Lo be accepLable.
8. lollow up wlLh hls C 2-4 weeks posLop."
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1he paLlenL should be lnformed of your recommendaLlons. 1hls noLe should be communlcaLed Lo
Lhe surgeon, Lhe prlmary care provlder, and Lo any speclallsLs as approprlaLe. 1he anesLhesla Leam
should have access Lo Lhls noLe. SLaLe how you may be reached. Make sure you know who ln your
The Preoperative Evaluation
The Medicine Consult Handbook 2011
lnsLlLuLlon wlll be seelng Lhe paLlenL posLop-lL may be you, Lhe surgery Leam alone, or an
lnLenslvlsL.

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1here are many sLandard" preoperaLlve LesLs LhaL do noL need Lo be done rouLlnely. ln some
cases, Lhere ls no consensus.

1, 11 noL requlred unless personal or famlly hlsLory of bleedlng dlaLhesls
CbLaln 1/ln8 ln paLlenLs Laklng warfarln
LCC
(APA/ACC guldellnes)
Class l:
vascular surgery and ! 1 Cllnlcal 8lsk lacLor*
lnLermedlaLe rlsk surgery ln paLlenLs wlLh CAu, Au, or
cerebrovascular dlsease.
Class lla: vascular surgery and no cllnlcal rlsk facLors
Class llb: lnLermedlaLe rlsk surgery and ! 1 cllnlcal rlsk facLor
ChesL x-ray As a general rule, noL necessary.
9!# be helpful for paLlenLs >30 years old undergolng Lhoraclc,
upper abdomlnal, or AAA surgery, or who have slgnlflcanL cardlac
or resplraLory dlsease (AC guldellnes 2006)
ulmonary luncLlon
1esLs (l1s)
CbLaln only lf needed Lo dlagnose prevlously unknown obsLrucLlve
lung dlsease.
used ln some surgery speclflc proLocols (e.g. Lhoraclc surgery)
ArLerlal 8lood Cas
(A8C)
CbLaln only lf susplclon for CC2 reLenLlon LhaL would affecL posLop
managemenL
*Cllnlcal 8lsk lacLors: ulabeLes, lschemlc PearL ulsease, PlsLory of CongesLlve PearL lallure,
Cerebrovascular ulsease, Chronlc kldney ulsease

Many preoperaLlve proLocols, wheLher from anesLhesla or Lhe surgeon, requlre cerLaln
preoperaLlve LesLs LhaL Lhe medlcal consulLanL may noL feel are requlred. 1he LCC and coagulaLlon
LesLs are common examples of LesLs LhaL are consldered overused. Cood communlcaLlon beLween
Lhe medlcal consulLanL, paLlenL, surgeon, and anesLhesla Leam ls essenLlal-lf Lhe LesLlng ls
requlred, we wlll ofLen go ahead and order lL so LhaL Lhe paLlenL's surgery wlll noL be cancelled, buL
also Lake Lhe slLuaLlon as an opporLunlLy Lo have a dlalogue wlLh Lhose requesLlng Lhe LesLs.



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