Pre-operative evaluation

1. Kerolus Shehata, MD
Pre-Operative Evaluation

2. Objectives
 To review preoperative planning and to delineate perioperative medication
adjustments commonly ordered by the internist.
 To review the role of clinical risk assessment in determining operative risk
 To review the role of the functional assessment in determining operative risk
 To review the role of surgery specific risk in determining operative risk
 To review the ACC/AHA guidelines for perioperative cardiovascular
evaluation for non-cardiac surgery
 To review the role of beta blockers in risk reduction for non-cardiac surgery

3. Components of the preoperative evaluation

4. Preoperative medication adjustment
 Antihypertensive agents are typically continued on the day of surgery, although there is
debate about three classes of antihypertensives; Diuretics.ACE-inhibitors andARBs.
 Traditionally, diuretics have been held on the morning of surgery because of
the concerns about intraoperative hypotension and hypokalemia. However, there is no
data showing worse outcomes on diuretics, leaving the choice to that of the clinical
team and the patient.
 Withholding ACE-inhibitors and ARBs was recommended based on evidence of
increased intraoperative hypotension. However long-term outcomes have not been
shown to be worse when continued on the morning of surgery. So, Continuation of
angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers
perioperatively is reasonable

5. Preoperative use of Hypoglycemic agents
 Discontinuation of all hypoglycemic medications (i.e., oral hypoglycemics or
insulin), even though the patient likely will not eat on the day of surgery, may lead to
elevations in serum glucose, fluid shifts, acidosis, diuresis and poor wound healing.
 Continuation of hypoglycemics in the patient fasting for surgery alternatively will risk
hypoglycemia.
 Patients treated with once-daily basal insulin should continue their basal dose,
possibly with a modest reduction (i.e., 20%) if the risk of hypoglycemia is high.
 Patients on twice-daily basal insulin should decrease the morning dose by one-
half to one-third. Prandial insulin should be held when the patient is not eating.
 Those on oral hypoglycemics should hold their hypoglycemics on the day of
surgery, but a decision must be made to substitute insulin perioperatively if glycemic
control is anticipated to be poor.
 Those with an average fasting glucose >250mg/dl should postpone elective
surgery to get glucose under better control.

6. Preoperative use of Statins , Aspirin & Steroids
 Statins should be continued in patients currently taking statins and scheduled for
non-cardiac surgery.
 Perioperative initiation of statin use is reasonable in patients undergoing
vascular surgery and in patients with clinical indications who are undergoing elevated-
risk procedures.
 In patients undergoing elective non-cardiac surgery who have not had previous
coronary stenting, it may be reasonable to continue aspirin when the risk of
potential increased cardiac events outweighs the risk of increased
bleeding.
 Patients on relatively low doses of steroids (i.e., <20mg/daily, or for < 3 weeks)
are unlikely to need stress-dose steroids.
 Patients getting minor procedures (regardless of the steroid dose or
duration) are also unlikely to need stress-dose steroids.
 In all other situations, consider either the administration of stress-dose steroids
or preoperative ACTH-stimulation testing to assess adrenal response.

7. Preoperative use of OTC medications, Tobacco and
Alcohol
 Ask specifically about OTC medications and nutritional supplements prior to surgery,
with particular attention to those medications that may contain aspirin or NSAIDs
or interact with anesthetics.
 Ask about tobacco use, and if present, use the opportunity to advocate for smoking
cessation. Quitting smoking four weeks preoperatively has been shown to reduce
postoperative complications.
 Ask about alcohol or other drugs of abuse, and plan accordingly. The autonomic
instability of alcohol withdrawal would complicate operative and post-operative care.

8. Medication adjustments on day of surgery

9. Preoperative use of Beta Blockers
 Initial studies showed that giving perioperative atenolol dramatically reduced the
risk of death and cardiac events perioperatively.
 Other studies suggested that patients with low cardiovascular risk given
perioperative beta blockers may actually be harmed by them
 The PeriOperative ISchemic Evaluation (POISE) trial showed that the treatment
group had more overall deaths and strokes as compared to those getting placebo.
 The POISE trial suggested that routine administration of high-dose beta blockers in the
absence of dose titration is not useful, and potentially harmful to beta-blocker
naïve patients undergoing non-cardiac surgery.
 The POISE trial recommended against starting perioperative beta blockers
on the day of surgery (which increases risk of harm).
 There is no evidence that titrating beta blockers impacts outcomes
 If you find a patient about to undergo elective surgery for whom long-term beta
blockers are indicated (but not prescribed), there is no evidence that starting them
before elective surgery is of benefit to the individual patient.

10. Clinical risk and beta blockers
 Since it is clear that patients at low risk might be harmed by the
addition of perioperative beta blockers, yet others at elevated risk may
benefit, we incorporate clinical risk into the decision on beta blockers.
 The Revised Cardiac Risk Index (RCRI) include the
following risk factors: Insulin dependent diabetes, CHF, CAD, CVA and CKD.

11. Preoperative cardiac testing
 Routine age-based preoperative EKG testing is NOT recommended, especially
for patients undergoing low-risk procedures even in patients with known CAD.
 Preoperative resting 12-lead EKG is reasonable for patients undergoing
intermediate to high risk surgery AND has known CAD, significant
arrhythmia, PAD, CVA, or other significant heart disease.
 Routine preoperative evaluation of LV function is NOT recommended.
 Reassessment of LV function in clinically stable patients with previously
documented LV dysfunction may be considered if there has been no assessment
within a year.
 As with CHF, if a patient with known valvular heart disease hasn't had an
echocardiogram in over 1 year, it is reasonable to obtain one in the
asymptomatic patient to reassess their valve.
 Coronary angiography in the asymptomatic patient has no value in preoperative
evaluation.

12. Non-cardiac preoperative testing
 Preoperative chest x-rays are not recommended EXCEPT when chest
symptoms are present, the patient has a history of heart or lung disease, the
patient is having chest/lung surgery, or the patient is 70 or older without a chest
x-ray in the past 6 months.
 Surgeons will typically request urinalysis before inserting hardware, and
increasingly request MRSA surveillance cultures before prosthetic joint replacement.
These recommendations are not evidence-based.
 Coagulation studies are often requested in patients with liver disease, on
anticoagulation, or undergoing neurosurgery.

13. "Routine" preoperative testing

14. Preoperative evaluation of the pulmonary system
 Pulmonary complications are the most common complications in surgical
patients.
 Perioperative pulmonary risk (e.g., prolonged intubation) increases
dramatically when the FEV1 < 1.5L.
 Low serum albumin (<3.5g/dL) is strongly predictive of perioperative
pulmonary complications.
 Patients with severe OSA have increased risk of myocardial infarction and
cardiac death relative to those without OSA when undergoing major noncardiac
surgery.
 Patients being referred for elective major noncardiac surgery who do have OSA
should be alerted that their risk is elevated relative to those without OSA, so they
can make a decision to proceed or postpone surgery based on that risk.
 If a new history of dyspnea is found during the preoperative evaluation,
elective surgery should be postponed.
 In patients with COPD or asthma, oral corticosteroid use in the past 12
months should be reviewed to screen for possible adrenal suppression.

15. Preoperative management of COPD

16. Preoperative non-cardiovascular risk
assessment
 ID: Elective surgeries are typically canceled in the presence of active infection.
 Hematologic: Look for a history or excess clotting (e.g., DVT/PE), coagulopathies
(inherited or acquired) and transfusion reactions.
 Endocrine: Look especially for potential adrenal suppression if prednisone more
than 5mg/day administered for greater than 2-3 weeks over prior year. Uncontrolled
hypothyroidism may be associated with decreased metabolism of anesthetic agents,
resulting in prolonged intubation. Uncontrolled hyperthyroidism risks thyroid
storm. Diabetes, especially if on insulin, is a clinical predictor of operative risk.
 Renal: creatinine greater than 2 mg/dl, is a clinical predictor of operative risk.
 Neurologic: CVA is a clinical predictor of operative risk.
 General: Look for history of prior complications from anesthesia. Exclude pregnancy in
female patients.

17. Preoperative cardiovascular risk assessment
 Pulmonary complications are the most common cause of perioperative morbidity.
 cardiac complications are the most common cause of perioperative mortality.
 Perioperative myocardial infarction is most common NOT during the surgery
itself, but rather in the immediate post-operative period (days 1-4).
 The greatest risk for recurrent MI with surgery is in those patients who have had an MI in
the past 60 days.
 Elective surgery be postponed for at least 60 days following MI.
 Those who have had balloon angioplasty with no stent should have elective surgery
postponed for 14 days.
 Those who have had PCI with BMS should have elective surgery postponed for 30 days.
 Those who have had PCI with DES: Necessary surgery can be done after 3 months if the
risk of delaying surgery is greater than the risk of an ischemic event.
 In all these instances, discussion with cardiology and the surgeon about whether to
continue/discontinue antiplatelet agents perioperatively is recommended

18. Elective surgery following PCI

19. Timing of Elective Non-cardiac surgery in
patients with coronary stents

20. Preoperative Assessment of Angina and HTN
 There is NO risk benefit in postponing elective surgery in a patient with stable, mild
(Class I or II) angina.
 Unstable angina, or severe angina (i.e., Class III or IV), is associated with more
significant cardiovascular risk, and should result in postponement of elective procedures.
 There is NO evidence that performing coronary artery revascularization merely
for the goal of reducing operative risk for another procedure is of benefit to a patient, and
this practice should not be done.
 A diastolic pressure below 110 mm Hg is regarded by most as an acceptable goal for
minimizing operative risk.
 Beta blockers are particularly effective at controlling perioperative hypertension.

21. Preoperative Assessment of CHF and
Valvulopathies
 CHF is associated with increased operative risk, and systolic heart failure carries more
risk than does diastolic heart failure.
 The majority of patients developing perioperative CHF have no prior history of CHF,
and most post-operative CHF occurs in the several hours immediately following
surgery.
 Patients with new or decompensated CHF should NOT undergo elective surgery.
 Routine echocardiography in the asymptomatic patient is not indicated.
 Patient with prior CHF who hasn't had an echocardiogram in the past year
should be considered for an echocardiogram to reassess left ventricular function.
 The first step in the preoperative assessment of the patient with valvular heart disease is
to determine if the patient is symptomatic from their valve. Patients with symptomatic
valvular heart disease should have elective surgery postponed.
 In those with known or suspected moderate or severe valvular heart disease yet remain
asymptomatic, if they haven't had an echocardiogram in the past year, an
echocardiogram is recommended. even asymptomatic patients with severe
valvular heart disease may undergo elective surgery as long as hemodynamic monitoring is
performed

22. Perioperative Management of Valvulopathies

23. Endocarditis prophylaxis
 There are 3 steps in determining if a patient about to undergo a surgical procedure needs
antibiotic prophylaxis. The first step is to determine if there is a high-risk cardiac
condition present. The second step is to determine if a high-risk procedure is being
performed. The third step is to determine the antibiotic to be used.
 There are actually very few procedures that warrant antibiotic prophylaxis:
invasive dental procedures (involving manipulation of the gingival tissues or perforation of
the oral mucosa), invasive respiratory tract procedures (involving incision or biopsy of the
respiratory mucosa), or invasive procedures of infected skin, skin structure, or musculoskeletal
tissues.
 Genitourinary or gastrointestinal procedures (including cystoscopy or endoscopy)
do not need endocarditis prophylaxis, unless there is active infection of the GU or GI tract
(for which organism-specific antibiotics that also cover enterococci should be used).
 High risk cardiac conditions include prior endocarditis, mechanical valves,
congenital heart disease, and cardiac transplant patients.
 If patient infected with MRSA, vancomycin or clindamycin should be used.

24. Endocarditis prophylaxis, Cont’d

25. Perioperative Assessment of Arrhythmias
 Most patients with stable arrhythmias do well and can proceed with surgery.
This includes individuals with supraventricular arrhythmias, such as A-fib, and
ventricular arrhythmias, such as NSVT.
 Patients with intraventricular conduction delay or BBB may also proceed
with surgery.
 In patients with pacemakers or defibrillators, cardiology should be
consulted to manage the device perioperatively (defibrillators may need to be
deactivated, necessitating close cardiac monitoring).
 Symptomatic or unstable patients with arrhythmias should have elective
procedures postponed.

26. Perioperative Assessment of Active cardiac
conditions
 Any "active cardiac conditions" should result in delay or cancellation of an
elective surgery.

27. Perioperative Assessment of the Functional
Status
 While the preoperative assessment will easily identify those patients at high risk merely
based on review of the PMHx and other features of the H&P, a subset of patients will have
underlying cardiovascular disease that has not yet become clinically apparent. The
stress of surgery may result in a cardiac (or pulmonary) complication that would not be
predicted by the history and physical examination. Because of this, attention has turned to
defining a functional assessment that will predict perioperative cardiac risk.
 Functional capacity has been standardized into units called metabolic equivalents
(METs), often used when exercise tolerance testing is performed.
 Poor exercise tolerance is defined as the inability to perform 4 METs of activity without
symptoms.
 Those able to perform 4 METs of activity without symptoms are typically cleared for
elective surgery, unless one of the clinical contraindications reviewed previously (e.g.,
decompensated heart failure) is present.
 Those unable to perform 4 METs of activity, or those whose functional status is
unknown may need pharmacologic stress testing based on their surgical risk.

28. METs of physical activities

29. Surgery-specific risk assessment
 when performing a preoperative assessment, not only do we consider the risk the patient
brings to the procedure, we must also consider the risk associated with the procedure. For
example, the stress on the cardiovascular system brought on by arthroscopic surgery of the
knee is going to be significantly less than that brought on by repair of an AAA.
 Cardiac complications are 2-5 times more common with emergency surgery than if the same
procedures were done electively.
 Patients undergoing low risk surgical procedures may proceed with surgery without further
cardiac testing.

30. Risk calculation and NSQIP
 The National Surgical Quality Improvement Program (NSQIP) calculator is used to
determine who might benefit from further testing (specifically pharmacologic cardiac
stress testing) for patients who either are undergoing intermediate/high risk surgery or
who have inadequate functional status.
 Should the risk of major adverse cardiac events (MACE) be <1%, elective surgery
may be performed without the need for further cardiac testing.
 Should the risk of MACE be >1%, pharmacologic cardiac stress testing (either
dobutamine stress echocardiography or radionuclide myocardial perfusion imaging)
should be obtained if it will guide management.
 The NSQIP risk calculator has replaced the use of the Revised Cardiac Risk Index in
estimation of surgical risk.

31. Putting it all together

32. References
 Fleisher LA, Fleischmann KE, Auerbach AD et al. 2014 ACC/AHA guideline on
perioperative cardiovascular evaluation and management of patients undergoing
noncardiac surgery. JourAmer Coll Cardiol. 2014; doi: 10.1016/j.jacc.2014.07.944.
 Lindenauer PK, Pekow P, Wang K et al. Lipid-lowering therapy and in-hospital mortality
following major noncardiac surgery. JAMA. 2004; 291:2092-99.
 Poldermans D, Bax JJ, Kertai MD et al. Statins are associated with a reduced incidence of
perioperative mortality in patients undergoing major noncardiac vascular surgery.
Circulation. 2003; 107:1848-51.
 Mangano DT, Layug EL, Wallace A, Tateo I. Effect of atenolol on mortality and
cardiovascular morbidity after noncardiac surgery. New Engl J Med. 1996; 335:1713-
1720. Moscussi M, Eagle KA. Coronary revascularization before noncardiac surgery. New
Engl J Med; 2004; 351:2861-3.
 Van Nostraud D, Kjelsberg MO, Humphrey EW. Presectional evaluation of risk from
Pneumonectomy. Surg Gynecol Obstet. 1968; 107:306-12.
 Gupta PK, Gupta H, Sundaram et al. Development and validation of a risk calculator for
prediction of cardiac risk after surgery. Circulation 2011; 124: 381-7.

33. Larry Bloom is a 54-year-old man presenting for preoperative assessment for
arthroscopic repair of his left rotator cuff. Past medical history is notable for myocardial
infarction one year ago, diabetes, hypertension and elevated cholesterol, for which he
takes aspirin 81mg, atenolol 50mg, metformin 1000mg, lisinopril 20mg, HCTZ 25mg
and atorvastatin 20mg daily. Review of systems is unremarkable, and is notable for the
absence of chest pain, dyspnea on exertion, coagulation disorders, or active infection.
Physical examination is unremarkable.
Which of the following medications should the patient continue on the day of surgery?
A.The patient should take all of his medications except aspirin on the day of surgery.
B.The patient should take all of his medications except metformin on the day of surgery.
C.The patient should take all of his medications except HCTZ on the day of surgery.
D. The patient should take all of his medications except metformin and HCTZ on the day
of surgery.

34. Suzanne Warren is an 80-year-old woman about to undergo femoral/popliteal bypass
surgery. Past medical history is notable for hypertension, prior CVA, high cholesterol,
and diabetes. Medications are aspirin 81mg daily, lisinopril 20mg daily, HCTZ 12.5mg
daily, atorvastatin 20mg daily and insulin. For this patient, which of the following about
perioperative beta blockers is correct?
A. Beta blockers are recommended in all patients undergoing vascular surgery.
B. Beta blockers pose serious risk to patients when started on the morning of surgery.
C. Beta blockers are indicated in all patients with at least one risk factor for MI.
D. Beta blockers should be started on this patient and titrated to a heart rate of 60BPM.

35. Tasha Jefferson is a 53-year-old woman with a history of bicuspid aortic valve and aortic
stenosis undergoing preoperative assessment for abdominal hysterectomy/salpingo-
oophorectomy for an ovarian mass. Past medical history is otherwise unremarkable. She is on
no medications. Her last echocardiogram was two years prior, showing mild aortic stenosis
and normal left ventricular function. She plays singles tennis for exercise. Physical
examination is normal other than a 1/6 diamond-shaped systolic murmur at the right upper
sternal border. Carotid upstrokes are normal. Which of the following cardiac tests are
indicated in this patient?
A. EKG only.
B. Echocardiogram only.
C. EKG and echocardiogram.
D. Dobutamine echocardiography.

36. Galina Reznikov is a 63-year-old woman with COPD who presents for preoperative
assessment prior to resection of a stage 1 adenocarcinoma of the left lung found during
lung cancer screening with low-dose CT. She has a several year history of COPD, with an
FEV1 of 1.7L. She often requires short courses of prednisone to manage COPD
exacerbations, most recently 6 weeks ago. Past medical history also includes hypertension
and hyperlipidemia. Current medications include tiotropium, fluticasone/salmeterol,
lisinopril and simvastatin. She is no longer smoking, and physical examination is
unremarkable.Which of the following is true?
A.The best predictor of pulmonary complications in this patient is her FEV1.
B. She should not use her inhalers on the morning of surgery.
C. She should be managed perioperatively as if she were adrenally suppressed.
D.All of the above are true.

37. Alex Vause is a 67-year-old woman with coronary artery disease in for preoperative
assessment for a left total knee replacement for severe osteoarthritis. Past medical history
is notable for myocardial infarction four months ago, treated with two drug-eluting stents
in her LAD. She has completed cardiac rehabilitation, and walks for 20 minutes daily,
limited by knee pain. She also has a history of hypertension, hyperlipidemia and tobacco
use. Medications include aspirin, clopidogrel, rosuvastatin, metoprolol, and lisinopril.
Physical examination is unremarkable. EKG shows evidence of prior anterior myocardial
infarction. Blood work is normal.The next step in perioperative management should be:
A. Obtain a dobutamine echocardiogram.
B. Proceed with surgery; discontinue aspirin and clopidogrel preoperatively.
C. Proceed with surgery; continue all medications.
D. Postpone surgery for eight months.

38. Tiffany Doggett is a 76-year-old woman undergoing preoperative assessment for right hip
arthroplasty. She has had degenerative arthritis for several years, and has gotten to the point
that she is unable to walk up one flight of stairs due to hip pain (she has no dyspnea or chest
pain, however). She is able to do chores around the house, including washing dishes and
preparing meals. How many METs of work is Ms. Doggett performing?
A. 1 MET
B. 4 METs
C. 10 METs
D. 20 METs

39. Sam Healy is a 73-year-old man with diabetes, hypertension, and COPD undergoing
preoperative evaluation for carotid endarterectomy. He is concerned about the risk of
surgery. His wife just underwent mastectomy for breast cancer, and his brother just
underwent cataract surgery.Which of the following is true?
A. Carotid endarterectomy, cataract surgery, and mastectomy are all low risk
procedures.
B. Carotid endarterectomy, cataract surgery, and mastectomy are all elevated risk
procedures.
C. Carotid endarterectomy and mastectomy are both elevated risk procedures; cataract
surgery is considered low risk.
D. Cataract surgery and mastectomy are both low risk procedures; carotid
endarterectomy is considered elevated risk.

40. 56-year-old woman with rheumatoid arthritis and hypertension undergoing
preoperative evaluation for nephrectomy for a presumed renal cell carcinoma. Past
history is notable for rheumatoid arthritis and hypothyroidism. Medications include an
interleukin-6 receptor inhibitor, methotrexate, prednisone and levothyroxine.
Functional status is unknown. You discuss her medications with rheumatology and plan
to cover her presumed adrenal suppression with corticosteroids. You turn to surgical
risk assessment; which of the following is true?
A. If this procedure can be done laparoscopically, she may proceed with surgery without
consideration of further testing.
B. She has no Revised Cardiac Risk Index risk factors, which is the best assessment tool
to assess her surgical risk.
C. She should have surgical risk assessed with a risk calculator; if risk of a major cardiac
event is >1%, pharmacologic cardiac stress testing should be performed.
D.All of the above are true.

41. ThankYou