Updated: 6/24/2018

Preoperative Evaluation

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Snapshot
  • A 40-year-old obese man presents to the emergency room with a large umbilical hernia and intermittent abdominal pain. He has a past medical history of untreated chronic hepatitis C and unstable angina. On physical exam, ascites is noted. The umbilical hernia is reducible. On laboratory evaluation, his bilirubin is 3.2 mg/dL, prothrombin time is 32 seconds, and INR is 2.2. The surgeon is reluctant to operate on this patient due to his elevated risk factors.
Introduction
  • The overall risk of surgery is low in healthy patients
  • Screening is not indicated unless there is a clinical indication
  • Baseline tests
    • complete blood count
      • > 65 years of age undergoing major surgery
      • younger patients undergoing surgery expected to have significant blood loss
    • serum creatinine
      • > 50 years of age undergoing > intermediate risk surgery
      • renal disease
    • pregnancy test
      • all women in their reproductive age
    • electrocardiogram (ECG)
      • coronary artery disease
      • arrhythmias
      • peripheral artery disease
      • cerebrovascular disease
      • structural heart disease
    • chest radiograph
      • underlying cardiac or pulmonary disease
      • abdominal or thoracic surgery
      • obesity
        • increased risk of pulmonary complications
  • To identify comorbidities that may preclude surgery
    • the most common precluding factor is cardiovascular disease
Cardiac Risk Assessment
  • Indications
    • ejection fraction < 35%
    • recent myocardial infarction
      • defer surgery for 6 months
    • decompensated congestive heart failure
      • optimize with medication prior to surgery
    • unstable, severe, or progressive angina
      • perform cardiac catheterization to evaluate for possible coronary revascularization
    • significant arrhythmias
    • severe valvular disease
  • Assessments
    • ECG
    • stress test
    • echocardiography
    • chest radiograph
Pulmonary Risk Assessment
  • Indications
    • smoking
      • compromises ventilation
      • patients should cease smoking for 8 weeks prior to surgery
    • dyspnea of unknown origin
    • obstructive sleep apnea (OSA)
      • may require altered anesthetic management
  • Assessments
    • order pulmonary function testing to evaluate forced expiratory volume in 1 second (FEV1)
      • If FEV1 is abnormal, obtain a blood gas
    • screen for OSA
    • chest radiograph
Hepatic Risk Assessment
  • Indications
    • cirrhosis or acute liver disease
  • Assessment
    • liver enzyme tests
 Renal Risk Assessment
  • Indications
    • any underlying renal disease
      • give fluids before and during surgery
    • patients undergoing urologic surgery
    • clinical indication of urinary tract infection
    • dialysis
      • dialyze 24 hours prior to surgery
  • Assessment
    • urinalysis
    • serum creatinine
Hemostasis Risk Assessment
  • Indications
    • personal or family history of a bleeding disorder
    • liver disease, which may affect clotting factor production
  • Assessments
    • prothrombin time (PT)
    • activated partial thromboplastin time (aPTT)
    • platelet count

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