Preoperative Evaluation of the Noncardiac Surgical Patient
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- Preoperative medical evaluation should determine the presence of established or unrecognized disease or other factors that may increase the risk of perioperative morbidity and mortality in patients undergoing surgery.
- Specific assessment goals include:
- Conducting a thorough medical history and physical examination to assess the need for further testing and/or consultation
- Recommending strategies to reduce risk and optimize patient condition prior to surgery
- Encouraging patients to optimize their health for possible improvement of both perioperative and long-term outcomes
- Synonym(s): Preoperative diagnostic workup; Preoperative preparation; Preoperative general health assessment
Overall patient morbidity and mortality related to surgery is low. Multiple studies have shown an average mortality rate of ~1% for patients undergoing a full spectrum of surgical procedures. Preoperative patient evaluation and subsequent optimization of perioperative care can reduce both postoperative morbidity and mortality.
- Functional capacity (1): Exercise tolerance is one of the most important determinants of cardiac risk:
- Self-reported exercise tolerance may be an extremely useful predictive tool when assessing risk. Patients unable to meet a 4 metabolic equivalent (MET) demand (defined in the “Diagnosis” section) during daily activities have increased perioperative cardiac and long-term risks.
- Patients who report good exercise tolerance require minimal, if any, additional testing.
- Levels of surgical risk:
- High: Aortic, major vascular, and peripheral vascular surgery
- Intermediate: Intraperitoneal, intrathoracic, carotid endarterectomy, head/neck, orthopedic, and prostate surgery
- Low: Endoscopic, superficial, cataract, breast, and ambulatory surgery
- Clinical risk factors (1): History of ischemic heart disease, the presence of compensated heart failure or a history of prior congestive heart failure (CHF), cerebrovascular disease, diabetes mellitus (DM), and renal insufficiency; these risk factors plus surgical risk can dictate the need for further cardiac testing.
- Age: Patients >70 years of age are at higher risk for perioperative complications and mortality and have a longer length of stay in the hospital postoperatively. (Likely attributed to increasing medical comorbidities with increasing age.) Age alone should not be a deciding factor in the decision to proceed with surgery (2).