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Updated: Dec 3 2021

Preoperative Evaluation

  • 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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