Preoperative Evaluation

Preoperative Evaluation - Setting the Stage

• Primary Goal: Enhance patient safety; ↓ perioperative morbidity & mortality.
• Key Objectives:
  • Identify patient-specific & procedure-related risks.
  • Implement strategies for risk mitigation.
• Core Components:
  • Detailed history (medical, surgical, medications, allergies, social).
  • Targeted physical examination.
  • Judicious investigations; avoid routine panels.
• Modern Approach: Collaborative risk assessment & optimization, not just "clearing" for surgery.

⭐ Preoperative evaluation is a process of risk stratification and optimization, aiming to reduce complications, rather than a simple "clearance" for surgery.

Preoperative Evaluation - Heart Matters Most

Goal: Min. perioperative MACE.

• Risk Stratification:
  • RCRI: 6 factors (1pt each)
    • High-risk surgery (vasc, intra-cavity)
    • Hx IHD
    • Hx CHF
    • Hx CVA/TIA
    • Insulin for DM
    • Creatinine >2 mg/dL
  • RCRI Score & MACE: 0 pts (0.4%), 1 pt (0.9%), 2 pts (6.6%), ≥3 pts (11%).
  • METs: <4 (poor, ↑ risk).
• Algorithm Basics:
  • Emergency? → OR, peri-op optimization.
  • Active Cardiac (ACS, sev. valve dz)? → Postpone, treat first.

• Perioperative Meds:
  • β-blockers: Cont. if on. Consider if ≥3 RCRI (HR 55-70).
  • Statins: Cont. Consider vascular surg.
  • Aspirin: Cont. if MACE risk > bleed.

⭐ <4 METs (poor capacity) sig. ↑ MACE risk, even w/ low RCRI.

Preoperative Evaluation - Beyond the Heart

• Pulmonary:
  • Risks: Age >50, COPD, smoking, OSA, albumin <3.5. ARISCAT.
  • Mgmt: Quit smoking (4-8 wks), PFTs if dyspnea. Post-op: IS.

• Renal:

  • Risks: CKD (eGFR <60), DM, HTN, nephrotoxins.
  • Mgmt: Hydration, avoid NSAIDs, adjust drug doses.

• Hepatic:

  • Assess: Child-Pugh, MELD (>10-15 = high risk).
  • Mgmt: Correct coagulopathy, manage ascites.

• Endocrine:

  • DM: Target glucose 140-180 mg/dL. Adjust meds (↓ basal insulin 20-50%).
  • Thyroid: Aim euthyroid. Postpone if severe dysfunction.
  • Adrenal Insufficiency: Stress dose steroids if chronic use (>5mg prednisone/day >3wks).
    • Mod. stress: Hydrocortisone 50-75mg IV.
    • Major stress: Hydrocortisone 100-150mg IV.

  ⭐ Chronic steroid users (prednisone ≥5mg/day for >3wks) need perioperative stress-dose steroids to prevent adrenal crisis.

Preoperative Evaluation - Pills & Plans

• General: Continue most. Hold: anticoagulants, some antidiabetics.
• Cardio:
  • BBs: Continue.
  • ACEi/ARBs, Diuretics: Hold AM of surgery.
  • Aspirin: Continue if high cardiac/low bleed risk; else stop 5-7d.
  • Clopidogrel: Stop 5-7d.
  • Warfarin: Stop 5d (INR < 1.5); bridge if high risk.
  • DOACs: Stop 24-72h (drug/renal).
• Endo:
  • OHAs: Hold AM. Metformin hold 24-48h if contrast/renal.
  • Insulin: ↓ dose (1/2 long-acting); hold short/rapid.
  • Steroids: Stress dose if >5mg pred for >3wks/yr.
  • OCPs/HRT: Stop 4-6wks if high VTE risk.
• Psych:
  • SSRIs/TCAs: Continue.
  • MAOIs: Stop 2wks (consult).
• Herbal: Stop 1-2wks (Ginkgo, Ginseng, Garlic). 📌 "Stop Gs".

⭐ Continue beta-blockers in chronic users perioperatively to prevent cardiac events.

High‑Yield Points - ⚡ Biggest Takeaways

• ASA classification is fundamental for overall surgical risk.
• RCRI identifies 6 predictors for Major Adverse Cardiac Events (MACE).
• Functional capacity <4 METs signifies increased perioperative risk.
• Continue chronic β-blockers; manage diabetes with insulin, hold most oral agents.
• Stop aspirin 5-7 days pre-op (unless high cardiac risk); manage anticoagulants based on risk.
• Advise smoking cessation >4 weeks preoperatively to reduce complications.
• Avoid routine labs in asymptomatic, low-risk patients for minor surgery.