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