pre op

1. Preoperative Evaluation and
Clearance for Surgery
Joshua Steinberg MD
Wilson Family Medicine Residency
Binghamton, New York

2. Your pt, 72 y.o.
Symptomatic
gallstones
Going for lap chole

3. Special Kind of Visit
Family Physician usually serves just one
person at a visit
At a Preoperative Evaluation visit, we
serve three parties

4. Whom We
Serve

5. Goal of Pre-Op Eval
At VERY LEAST, what does surgeon
want to hear from you?
CNY Cardiology
1234 Main St.
Wherever, NY 67890
Yours Truly,
Fred the Cardiologist
Dear Bill the Orthopedist,
I had the pleasure of seeing Mrs. Mabel Jones at your kind
request.
You may proceed to surgery.

6. Let’s do better than
minimum!
What should we do at the preoperative
evaluation of a patient?
What would the surgeon and
anesthesiologist like us to do?
How could we help a patient endure the
challenges of surgery and recovery?
How could we help surgeon &
anesthesiologist give good care?

7. Organize the Activities
Suggest/implement
periop interventions
4
Optimize medical issues
2
Consider cardiac status
3
Report medical issues
1

8. Full History
HPI: “asked by Dr. Aronis to evaluate pt prior
to cholecystectomy for gallstones”
Past Medical History: everything
Past Surgical Hx (note problems bleeding or anesthesia)
Allergies & Reactions, Meds
FamHx (note problems anesthesia, bleeding)
SocHx: EtOH, tobacco, drugs
ROS: cardiac, those pertinent to PMHx, functional capacity
Report medical issues
1

9. Physical Exam
Vitals
Cardiocirculatory
Pulmonary
Abdominal
anything else you think is pertinent and
helpful (neuro exam, mental status exam,
skin exam, etc.)
Report medical issues
1

10. Assessment & Plan
Report medical issues
1
10/27/11, 8:15 am Samantha Smith
S: Asked by Dr. Aronis to evaluate pt with cholecystitis
prior to lap chole.
PMHx, PSHx, All, Meds, SocHx, FamHx, ROS
etc.
O: vitals, lungs, heart, abd, ext,
etc.
A/P:
1. Preop clearance: clear to proceed to surgery (more later)
2. Asthma: mild, stable, continue Flovent MDI
3. Chronic Renal Insufficiency: creat stable at 1.5
baseline
4. Anemia: chronic, from malabsorption after bariatric
surgery, recommend check Hct post-op
5. Please note anaphylactic Cefazolin allergy
signed,
JP Intern

11. Not so rosy
after nausea and vomiting of cholecystitis,
dehydrated, creat bumped to 2.1
asthma not controlled
HTN uncontrolled
Diabetes uncontrolled
COPD or CHF exacerbated
Optimize medical issues
2

12. Not so rosy
Optimize medical issues
2
10/27/11, 8:15 am Samantha Smith
S: Asked by Dr. Aronis to evaluate pt with cholecystitis
prior to lap chole.
PMHx, PSHx, All, Meds, SocHx, FamHx, ROS
O: vitals, lungs, heart, abd, ext,
etc.
A/P:
1. Preop clearance: pending items 2-4, I anticipate pt
will be clear to proceed to surgery
2. Dehydration: giving 2 L NS
3. Chronic Renal Insufficiency: recheck after IVF, aim to
get back to baseline creat 1.5
4. HTN: SBP 197/98 unsafe for surgery, will resume
Amlodipine and Coreg
5. Severe O2 dept COPD: it’s awful, horrendous, 115.3
pack-year smoking hx, but optimized on meds and at
baseline
signed,
JP Intern

13. Check for
sub-optimal stuff
All kinds of labs & workup you could do preop checking
if anything is suboptimal
BUT, every guideline recognizes that the yield of useful
results that influence care is VANISHINGLY LOW.
Over-testing is rampant
 many preop tests already ordered by surgeon
 if you choose tests, order only ones indicated
 avoid cost, risk of false positives, unnecessary delay surgery
K+ or BMP: certainly digoxin, diuretics, ACE/ARB, ok for others
CBC: anything suggests anemia or blood loss
Optimize medical issues
2

14. Check for
sub-optimal stuff
CXR: only for s/sx new or unstable cardiopulm disease, 4
organizations beg you to stop routine CXR
Coags: known hx coag d/o, hx suggests new coag d/o, on
anticoagulant, needs anticoagulant post-op, otherwise don’t do
UA: urologic surgery, prosthetic implants, otherwise don’t do
EKG: most patients (ICSI vs ACC)
 any cardiovasc risk factors, age 65+, any cardiovascular s/sx,
surgery of intermediate or high risk
anything else you can justify, i.e. renal fxn for known/suspected
kidney disease, LFT’s for known/suspected liver disease, HCG,
etc.
Never do any testing before cataract surgery
Optimize medical issues
2

15. Cardiac Eval Algorithm
American College of Cardiology (ACC)
guideline for stepwise consideration of
cardiac status
revised 1997, 2002, 2007, 2014
always gets easier since evidence shows that
pts simply do well!
Consider cardiac status
3

16. Consider cardiac status
3
Cardiac
Eval
Algorithm

17. Step 1
Consider cardiac status
3
Emergency surgery?
If so, go to the OR – it’s an emergency!
Figure things out and clean up any mess
post-op!

18. Step 2
Consider cardiac status
3
Acute Coronary Syndrome current or recent?
 clinical syndromes of acute coronary ischemia
including unstable angina, STEMI, NSTEMI
If so, evaluate, treat, recover, optimize, and
then reconsider OR

19. Step 3
(and 4)
Consider cardiac status
3
Risk of major adverse
cardiac event (MACE) < 1%?
ACC offers 3 validated
schemes to estimate risk
 RCRI, ACS NSQIP Surgical Risk
Calculator (online), ACS NSQIP MICA
calculator (.xls!)
Risk
0-1: low
2+: high
Certain surgeries very low
risk no matter what
 e.g. ophthalmic, plastic, etc.
If low risk, go to OR

20. Step 5
Consider cardiac status
3
Good functional
capacity?
If so, go to OR

21. Steps 6 & 7
Consider cardiac status
3
Urgent or elective surgery
No acute coronary syndr.
Elevated risk surgery
Poor or unknown
functional capacity
Consider whether further
testing would impact
decision making or
perioperative care

22. Steps 6 & 7
Consider cardiac status
3
Would further testing
would impact decision
making?
 would pt facing surgery agree
to cath-stent-CABG and post-
procedure delay if stress
testing found ischemia?
 would pt facing surgery and
possible coronary
revascularization opt for non-
surgical tx instead (e.g.
chemo, xrt for cancer)

23. Cardiac Eval Algorithm
Consider cardiac status
3
10/27/11, 8:15 am Samantha Smith
S: Asked by Dr. Aronis to evaluate pt with cholecystitis
prior to lap chole.
PMHx, PSHx, All, Meds, SocHx, FamHx
ROS: no cardiac sx, good functional capacity
O: vitals, lungs, heart, abd, ext,
etc.
A/P:
1. Preop clearance: according to 2014 ACC guideline, pt
is clear to proceed to surgery
2. Asthma: mild, stable, continue Flovent MDI
3. Chronic Renal Insufficiency: creat stable at 1.5
baseline
4. Anemia: chronic, from malabsorption after bariatric
surgery, recommend check Hct post-op
5. Please note anaphylactic Cefazolin allergy
signed,
JP Intern

24. Periop interventions
Lots of useful things you could do before and
after surgery
 smoking cessation
 alcohol cessation/detox
 get the Foley catheter out early
mainly medication management
 beta blockers
 insulin
 warfarin & bridging heparins
 aspirin & plavix
Suggest/implement
periop interventions
4

25. Beta-blockers
if on one, stay on it
add beta-blocker periop?
numerous trials show reduced MI’s for pts
with significant MI risk
then one showing MI benefit, CVA harm
 Metoprolol high dose and no titration
ACC has softened recommendation but still
says offer beta-blockade for higher risk
cardiovascular pts with higher risk surgeries
and take time to titrate
Suggest/implement
periop interventions
4

26. Diabetes & Insulin
Mild hyperglycemia is preferable to hypoglycemia
Don’t take oral hypoglycemics on day of procedure
Don’t take short-acting insulin morning of procedure
Long-acting or intermediate insulin may be used to
cover basal insulin needs; 50%-100% of usual dose is
often reasonable
Insulin pumps should be continued but only to provide
basal insulin coverage
Details of insulin recommendations influenced by
insulin sensitivity of patient, timing of procedure,
length of procedure, and how long patient will need to
be NPO following the procedure.
Suggest/implement
periop interventions
4

27. Warfarin & bridging
Heparins
ACCP guideline recommends you handle this based upon
risk of thromboembolism during non-anticoagulated time
Basically stop Warfarin 5 days before surgery, resume
when surgical wounds hemostatic and clinical situation
favorable
Depending on level of risk of thromboembolic event, cover
pt with a Heparin product up until time of surgery and as
soon after surgery as pt deemed safe for anticoagulation
Suggest/implement
periop interventions
4
day preop 5 4 3 2 1 surgery 1 2 day postop
WARFARIN ---> // ??? bridging Heparin ??? ---> // WARFARIN +/- Heparin --->

28. Aspirin
ACC points out that evidence does not clearly support
benefit of Aspirin to prevent peri/post-operative MI’s (in
non post-stent pts).
Aspirin causes more bleeding during surgery.
Thus much weaker recommendation on continuing
Aspirin during surgery for high ischemia-risk pts and
much more permission to stop aspirin in anyone
Should be discussed and negotiated with the surgeon
Strong recommendation to continue Aspirin if pt was on
Aspirin-Clopidogrel combination (“dual antiplatelet
therapy” or DAPT) and both cannot be continued during
surgery when highly necessary…
Suggest/implement
periop interventions
4

29. Aspirin & Clopidogrel
Most patients on Clopidogrel are on it with Aspirin
(DAPT) in the 12 months after stent
Stent thrombosis rates super-high 1st 4-6 wks,
somewhat high therafter, especially for DES
Try not to do surgery 4-6 wks after stent at all and
not for 365 days after DES
If must operate, try to go to OR on DAPT, and if
DAPT too dangerous, try to go to OR on Aspirin
alone, restarting Clopidogrel ASAP after
This stuff should be discussed and negotiated with
the surgeon
Suggest/implement
periop interventions
4
or the other P2Y12 inhibitors

30. Periop Med Mgmt
Suggest/implement
periop interventions
4
10/27/11, 8:15 am Samantha Smith
S: Asked by Dr. Aronis to evaluate pt with cholecystitis
prior to lap chole.
PMHx, PSHx, All, Meds, SocHx, FamHx
ROS: no cardiac sx, good functional capacity
O: vitals, lungs, heart, abd, ext,
preop labs, EKG
A/P:
1. Preop clearance: according to 2014 ACC guideline, pt
is clear to proceed to surgery
2. A-fib/Anticoag: as pt is low risk, will stop Coumadin 5
days before surgery and recommend resume when
hemostasis achieved
3. DM II: stop Humalog & Metformin, give half dose
Lantus night before surgery, resume each when
taking PO post-op
4. Please note anaphylactic Cefazolin allergy
signed,
JP Intern

31. Agenda for Preop Eval
Suggest/implement
periop interventions
4
Optimize medical issues
2
Consider cardiac status
3
Report medical issues
1

32. Preoperative Evaluation
So you’ve got it all memorized now?
Big Important Med School
1234 Main St.
Wherever, NY 67890
Yours Truly,
Bob the Med Student
Dear Dr. Steinberg,
That’s a crazy amount o’ stuff to
keep straight!

33. There’s an App for That…