Preoperative medical evaluation of the healthy patient

Official reprint fro www.up 2010

Preoperative medical evaluation of the healthy patient Author Section Editor Gerald W Smetana, MD Mark D Aronson, MD

Pracha Eam

Last literature review version 18.2: May 2010 | This topic last updated: May 18, 2010 INTRODUCTION Clinicians are often asked to evaluate a patient prior to surgery. T he medical consultant may be seeing the patient at the request of the surgeon, or ma y be the primary care clinician assessing the patient prior to consideration of a surgical referral. The goal of the evaluation of the healthy patient is to detect and treat unrecognized disease that may increase the risk of surgery above baseline. The evaluation of healthy patients prior to surgery is reviewed here. Preoperativ e assessments for specific systems issues and surgical procedures are discussed sep arately (see "Estimation of cardiac risk prior to noncardiac surgery" and see topics on s pecific conditions). RATIONALE FOR SELECTIVE TESTING The prevalence of unrecognized disease that impacts upon surgical risk is low in healthy individuals. Nevertheless, clinician s often perform laboratory tests in this group of patients out of habit and medicolegal c oncern, with little benefit and a high incidence of false positive results. Representative stu dies that have addressed this issue include:

In a trial of 1061 ambulatory surgical patients randomly assigned to preoperativ testing or no testing, there was no difference in perioperative adverse events or events within 30 days of ambulatory surgery [1]. Patients assigned to testing could rece ive a complete blood count, electrolytes, blood glucose, creatinine, electrocardiogram, and/or chest radiograph, based on the Ontario Preoperative Testing Grid. Medical consultants commonly see patients before planned cataract surgery. In y institutions, guidelines still require routine laboratory testing despite compell ing evidence showing no benefit of such testing. A systematic review of three randomized trial

s of testing versus no testing in a total of 21,531 cataract surgeries found that adverse even ts did not differ between the two groups [2]. Institutions may safely eliminate a requiremen t for routine laboratory tests before cataract surgery. of routinely ordered tests would not have been performed if testing had only been do ne for recognizable indications; only 0.22 percent of these revealed abnormalities that might influence perioperative management [3]. Further chart review determined that thes e abnormalities were not acted upon, nor did they have adverse surgical consequence s.

In a retrospective study of 2000 patients undergoing elective surgery, 60 perc

http://www.uptodate.com/online/content/topic.do?topicKey=med_cons/6474&view=print 1/22/2010 Preoperative medical evaluation of the healthy patient One report found that only ten routine laboratory test results in 3782 patients equired treatment; just one of these required pharmacologic treatment [4]. In a second re view of 5003 preoperative screening tests in 2570 patients, only 104 tests were abnormal and potentially significant [5]. Screening modified preoperative management in only f our patients. Predictive value There are several arguments for avoiding routine preoperative te sts. Normal test values are usually arbitrarily defined as those occurring within two standard deviations from the mean, thereby ensuring that 5 percent of healthy individuals who have a single screening test will have an abnormal result. As more tests are ordered, the likelihood of a false positive test increases; a screening panel containing 20 in dependent tests in a patient with no disease will yield at least one abnormal result 64 per cent of the time (table 1). Thus, the predictive value of abnormal test results is low in healthy patients wi th a low prevalence of disease (table 2). Aside from possibly causing patient alarm, the a dditional testing prompted by false positive screening tests leads to unnecessary costs, ri sks, and a potential delay of surgery. In addition, clinicians often fail to act upon abnorm al test results from routine preoperative testing, thereby creating an additional medicolegal ris k.

A review of studies of routine preoperative testing pooled data and estimated the incidence of abnormalities that affect patient management and the positive and negative lik elihood ratios for a postoperative complication (table 3) [6]. For nearly all potential l aboratory studies, a normal test did not substantially reduce the likelihood of a postopera tive complication (the negative likelihood ratio approached 1.0). Positive likelihood ratios were modest, and they exceeded 3.0 for only three tests (hemoglobin, renal function, a nd electrolytes); however, clinical evaluation can predict most patients with an abn ormal result. This was illustrated by the low incidence of a change in preoperative man agement based on an abnormal test result (zero to 3 percent). CLINICAL EVALUATION In general, the overall risk of surgery is extremely low in healthy individuals. Therefore, the ability to stratify risk by commonly performe d evaluations is limited. Screening questionnaire Screening questions appear on many standard institutional preoperative evaluation forms. One validated screening instrument, derived from 1 00 patients, comprises 17 questions that allowed nurses to identify those patients w ho would benefit from a formal preoperative evaluation by an anesthesiologist [7] (table 4 ). The questions chosen for this questionnaire were devised to detect pre-existing condi tions shown to be associated with perioperative adverse events. Age A number of commonly employed and validated indices consider age as a minor component of preoperative coronary risk. (See "Estimation of cardiac risk prior t o noncardiac surgery".) Some studies found a small increased risk of surgery associated with advancing ag e [8,9]. In a review of 50,000 elderly patients, for example, the risk of mortality with e lective surgery increased from 1.3 percent for those under 60 years of age, to 11.3 perce nt in the 80 to 89 year-old age group [9]. Among 1.2 million Medicare patients undergoing e lective surgery, mortality risk increased linearly with age for most surgical procedures [10].

http://www.uptodate.com/online/content/topic.do?topicKey=med_cons/6474&view=print 1/22/2010 Preoperative medical evaluation of the healthy patient Operative mortality for patients 80 years and older was more than twice that of p

atients 65 to 69 years old. In addition to the minor influence of age on perioperative cardiac risk, there is more robust literature supporting age as an independent risk factor for postoperative pulmona ry complications. Age was one of the most important patient-related predictors of pu lmonary risk, even after adjusting for common age-related comorbidities, in a systematic review [11]. (See "Evaluation of preoperative pulmonary risk".) In contrast, some studies have found little relation between age and mortality ra tes due to surgery. One study reported the outcomes of surgery in 795 patients over 90 years of age [12]. No patients were Class I as classified by the American Society of Anesthesi ologists (ASA) classification (table 5); 80 percent were ASA Class III or greater. Despite higher perioperative mortality rates in the elderly, survival at two years was no differ ent than the actuarial survival in matched patients not undergoing surgery [12]. A larger stud y of 4315 patients also found a higher perioperative complication and mortality rate in old er individuals, but the mortality rate was low [13]. Among 31 patients age 100 years and older undergoing surgery requiring anesthesia, perioperative and one-year mortali ty rates were similar to matched peers from the general population [14]. Much of the risk associated with age is due to increasing numbers of comorbiditie s that confer excess risk. After adjusting for comorbidities more common with age, the i mpact of age on perioperative outcomes is modest. Thus, age should not be used as the sole criterion to guide preoperative testing or to withhold a surgical procedure [15]. Exercise capacity All patients should be asked about their exercise capacity as p art of the preoperative evaluation. Exercise capacity is an important determinant of ove rall perioperative risk; patients with virtually unlimited exercise tolerance generall y have low risk. The ability to walk two blocks on level ground or carry two bags of groceries up one flight of stairs without symptoms are simple questions that can give a rough assessment of patient risk [16]. These activities expend approximately 4 metabolic energy equivalents ( METs) [17]. (See "Estimation of cardiac risk prior to noncardiac surgery", section on ' Functional capacity'.) In general, healthy patients who can perform these activities as part of their da ily routine

have a low risk for major postoperative complications. This was illustrated in a study of 600 consecutive patients undergoing major surgery [18]. Investigators asked each pati ent to estimate the number of blocks that they could walk on level ground and the number of flights of stairs they could climb without symptoms. The authors defined poor exe rcise capacity as the inability to either walk four blocks or climb two flights of stai rs. Patients reporting poor exercise capacity had twice as many serious postoperative complica tions as those who reported good exercise capacity (20 versus 10 percent, respectively). T here was also a significant difference in cardiovascular complications (10 versus 5 percen t), but not for total pulmonary complications (9 versus 6 percent). Medication use A history of medication use should be obtained for all patients be fore surgery and should specifically include over-the-counter medications. Aspirin, ib uprofen, and other nonsteroidal anti-inflammatory drugs are readily available and are asso ciated with an increased risk of perioperative bleeding. Specific inquiry about use of

http://www.uptodate.com/online/content/topic.do?topicKey=med_cons/6474&view=print 1/22/2010 Preoperative medical evaluation of the healthy patient complementary and alternative medications should also be part of the preoperative assessment. A detailed discussion of perioperative medication management is prese nted separately. (See "Perioperative medication management".) Obesity Contrary to popular belief, in noncardiac surgery, obesity is not a risk factor for most major adverse postoperative outcomes, with the exception of pulmonary emboli sm. None of the published and widely disseminated cardiac risk indices include obesit y as a risk factor for postoperative cardiac complications. However, in cardiac surgery, some studies have shown higher complication rates fo r obese patients, including increased hospital stay [19], wound infections [19,20], prolo nged mechanical ventilation [20], and atrial arrhythmias [20,21]. Representative studies related to postoperative mortality in noncardiac surgery i nclude: In a matched case control study of 1962 patients undergoing noncardiac surgery, obesity was not associated with increased mortality (1.1 percent in obese patient s versus 1.2 percent in controls) [22].

In a large, multi-institutional, prospective cohort of 118,707 patients undergoi g nonbariatric general surgery, obesity was inversely associated with postoperative mortality (OR 0.85, 95% CI 0.75-0.99), a phenomenon termed the 'obesity paradox' [23]. The authors suggest that the obese state carries a low-grade, chronic inflammatory th at may be 'primed' to mount an appropriate inflammatory and immune response to the stres s of surgery, in addition to supplying more nutritional reserve. Other studies relating to complications in noncardiac surgery found that obesity increases rates for wound infections, but has no effect on other postoperative complication s [24-28]. Obesity is also not a risk factor for postoperative pulmonary conditions other th an pulmonary embolism. In a review which found that the unadjusted relative risks fo r pulmonary complications due to obesity were 0.8 to 1.7, the incidence of pulmonar y complications was 21 percent in both obese and non-obese patients [28]. In anothe r systematic review, only one of eight eligible studies using multivariable analysi s to adjust for confounders found that obesity was a predictor of postoperative pulmonary ris k [11]. The one exception to the observation that obesity does not increase the risk of n oncardiac surgery is venous thromboembolism. Obesity is a major risk factor for postoperati ve deep venous thrombosis and pulmonary embolism. (See "Prevention of venous thromboembol ic disease in surgical patients".) LABORATORY EVALUATION Several review articles in perioperative consultation and most local institutional policies support a selective approach to preoperative te sting [3,6,16,29-32]. A practice advisory from the American Society of Anesthesiologist s recommends against routine preoperative laboratory testing in the absence of clin ical indications [29]. Timing of laboratory testing When laboratory tests are felt to be necessary, it i s probably safe to use test results that were performed and were normal within the past four months, unless there has been an interim change in clinical status. The validity of this approach was illustrated in an observational study which investigated the usefuln ess of

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Preoperative medical evaluation of the healthy patient 7549 preoperative tests performed in 1109 patients undergoing elective surgery [3 0]. The tests were duplicates of those performed within the year prior to surgery in 47 p ercent of cases:

Of 3096 previous results that were normal (as defined by hospital reference rang ) and performed closest to the time of but before admission (median interval two months ), only 13 (0.4 percent) values were outside a range considered acceptable for surgery. M ost of these abnormalities were predictable from the patient's history, and most were no t noted in the medical record.

In contrast, of 461 previous tests that were abnormal, 78 (17 percent) repeat va ues at admission were outside a range considered acceptable for surgery, suggesting that tests that have recently been abnormal should be repeated preoperatively. Laboratory studies While preoperative laboratory testing is not routinely indicat ed, selective testing is appropriate in specific circumstances, including patients wi th known underlying diseases or risk factors that would affect operative management or inc rease risk, and specific high risk surgical procedures. Specific laboratory studies commonly ordered for preoperative evaluation include a complete blood count, electrolytes, renal funct ion, blood glucose, liver function studies, hemostasis evaluation, and urinalysis [31]. Thes e tests are discussed below with indications for their use in specific populations and surger ies. Complete blood count Anemia is present in approximately 1 percent of asymptomatic patients; surgically significant anemia has an even lower prevalence [3]. However, anemia is common following major surgery and the preoperative hemoglobin level predicts postoperative mortality. As an example, a large observational stud y of older veterans (n = 310,311, age 65 years) found an increase in 30-day postoperative mor tality for patients with mildly abnormal preoperative hematocrits undergoing major nonca rdiac surgery, even in the absence of significant blood loss [33]. Adjusted mortality i ncreased by 1.6 percent (95% CI 1.1 to 2.2 percent) for every one percentage point increase o r decrease from a normal hematocrit, defined as 39.0 to 53.9 percent. The data cann ot distinguish whether an abnormal hematocrit serves as a marker for coexistent dise ase that increases mortality risk, or whether the anemia itself increases physiologic stre sses and

therefore complication rates. Thus, it is unclear if the increased risk is modifi able by interventions aimed at correcting the hematocrit. A baseline hemoglobin measurement is suggested for all patients 65 years of age o r older who are undergoing major surgery, and for younger patients undergoing major surge ry that is expected to result in significant blood loss. In contrast, hemoglobin measurem ent is not necessary for those undergoing minor surgery unless the history suggests anemia. The frequency of significant unsuspected white blood cell or platelet abnormaliti es is low [3]. Unlike the hemoglobin concentration, however, there is little rationale to s upport baseline testing of either. Nevertheless, obtaining a complete blood count, inclu ding white count and platelet measurement, can be recommended if the cost is not substantial ly greater than the cost of a hemoglobin concentration alone. There may be some cost s incurred due to follow-up of false positive results; however, with respect to pla telet counts, these costs do not appear to be substantial [34]. Renal function Mild to moderate renal impairment is usually asymptomatic; the

http://www.uptodate.com/online/content/topic.do?topicKey=med_cons/6474&view=print 1/22/2010 Preoperative medical evaluation of the healthy patient prevalence of an elevated creatinine among asymptomatic patients with no history of renal disease is only 0.2 percent [3,5]. However, the prevalence increases with age. In one study, for example, the prevalence among unselected patients aged 46 to 60 was 9. 8 percent [35]. In the revised cardiac risk index, a serum creatinine >2.0 mg/dL (177 mol/L) was one of six independent factors that predicted postoperative cardiac complications [36]. Renal insufficiency is also an independent risk factor for postoperative pulmonary comp lications [11] and a major predictor of postoperative mortality [37]. Renal insufficiency n ecessitates dosage adjustment of some medications that may be used perioperatively (eg, muscl e relaxants). For these reasons, it is reasonable to obtain a serum creatinine concentration in patients over the age of 50 undergoing intermediate or high risk surgery, although there i s no clear

consensus on this point. It should also be ordered when hypotension is likely, or when nephrotoxic medications will be used. Electrolytes The frequency of unexpected electrolyte abnormalities is low (0.6 percent in one report) [3]. In addition, the relationship between most of these derangements and operative morbidity is not clear. Furthermore, clinicians can pr edict most abnormalities based on history (for example, current use of a diuretic, angiotens in converting enzyme (ACE) inhibitor, or angiotensin receptor blocker (ARB), or know n chronic renal insufficiency). Thus, routine electrolyte determinations are NOT recommended unless the patient h as a history that increases the likelihood of an abnormality. Blood glucose The frequency of glucose abnormalities increases with age; almost 5 percent of patients over age 60 had an abnormal value in one report [35]. Most co ntrolled studies have not found a relationship between operative risk and diabetes [8,35], except in patients undergoing vascular surgery or coronary artery bypass grafting [38,39]. While the revised cardiac risk index identified diabetes as a risk factor for postoperative cardiac complications, only patients with insulin-treated diabetes were at risk [36]. The re is no evidence that asymptomatic hyperglycemia, in a patient not previously known to ha ve diabetes, increases surgical risk. Unexpected abnormal blood glucose results do not often influence perioperative management. As an example, one study evaluated the benefit of routine laboratory testing in 1010 presumably healthy patients undergoing cholecystectomy [5]. Eight patient s had unexpected elevations in preoperative serum glucose; only one of these patients d eveloped significant postoperative hyperglycemia and this was not recognized until after t otal parenteral nutrition was started. No patient in this study benefited from routine preoperative measurement of serum glucose. Thus, routine measurement of blood glucose is NOT recommended for preoperative he althy patients. Liver function tests Unexpected liver enzyme abnormalities are uncommon, occurring in only 0.3 percent of patients in one series [4]. In a pooled data ana lysis, only 0.1 percent of all routine preoperative liver function tests changed preoperative management (table 3) [6]. Severe liver function test abnormalities among patients with

http://www.uptodate.com/online/content/topic.do?topicKey=med_cons/6474&view=print 1/22/2010 Preoperative medical evaluation of the healthy patient cirrhosis or acute liver disease are associated with increased surgical morbidity and mortality, but it is not clear if mild abnormalities among patients with no known liver disease have a similar impact [40]. Clinically significant liver disease would mo st likely be suspected on the basis of the history and physical examination; thus, routine liv er enzyme testing is NOT recommended.

Tests of hemostasis Unexpected significant abnormalities of the prothrombin time (PT) or partial thromboplastin time (PTT) are uncommon [3,34]. In addition, the relationship between an abnormal result and the risk of perioperative hemorrhage is not well defined, but appears to be low, particularly in those who are thought to hav e a low risk of hemorrhage on the basis of history and physical examination [41,42]. In a pool ed data analysis, an abnormal PT had a positive likelihood ratio of 0 for predicting a po stoperative complication, and a negative likelihood ratio of 1.01 (table 3); in no case did t he finding of an abnormal PT change patient management or modify the likelihood of a complicati on [6]. Similarly, the bleeding time is not useful in assessing the risk of perioperative hemorrhage [43,44]. Thus, routine preoperative tests of hemostasis are NOT recommended. We advise tes ting in patients with a known bleeding diathesis or an illness associated with bleeding t endency (table 6). The role of preoperative hemostasis evaluation in patients undergoing intermediate to high risk surgical procedures is somewhat controversial. We sugge st NOT performing PT and PTT in such patients. Others, including authors for UpToDate, h ave suggested testing all patients undergoing intermediate to high risk surgical proc edures, as clinicians may forget to ask about bleeding, or patient history may be unreliable . As discussed above, there is no evidence to support this practice. (See "Preoperativ e assessment of hemostasis".) n of unsuspected renal disease and/or urinary tract infection. Asymptomatic renal dise ase can be detected by measurement of serum creatinine in selected patients (see 'Renal function' above). Urinary tract infections have the potential to cause bacteremia and post-surgical wound infections, particularly with prosthetic surgery [45]. Patients with positive uri

Urinalysis The theoretical reason to obtain a preoperative urinalysis is detecti

nalysis and urine culture are generally treated with antibiotics and proceed with surgery wit hout delay [46]. However, it is unclear whether a positive preoperative urinalysis and cultu re with subsequent antibiotic treatment prevent post-surgical infection. One study found no difference in wound infection between patients with normal and abnormal urinalysi s [47]. Another study found that patients with asymptomatic urinary tract infection detec ted by urinalysis had an increased risk of wound infection post-operatively, despite tre atment [48]. A cost-effectiveness analysis estimated that 4.58 wound infections in nonprosthet ic knee operations may be prevented annually by the use of routine urinalysis, at a cost of $1,500,000 per wound infection prevented [49]. Thus, routine urinalysis is NOT recommended preoperatively for most surgical proc edures. ELECTROCARDIOGRAM Electrocardiograms (ECGs) have a low likelihood of changing perioperative management in the absence of known cardiac disease. Nevertheless, detecting a recent myocardial infarction is important since it is associated with high surgical morbidity and mortality [8]. (See "Estimation of cardiac risk prior to noncardiac surgery".)

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The prevalence of abnormal ECGs increases with age [50]. Important ECG abnormalit ies in patients younger than 45 years with no known cardiac disease are very infrequent. The electrocardiogram alone may be a poor overall predictor of postoperative cardiac complications [51]. On the other hand, a preoperative ECG can be important as a b aseline to compare with postoperative ECG abnormalities. The 2007 American College of Cardiology/American Heart Association (ACC/AHA) Guid elines on Perioperative Cardiovascular Evaluation state that ECG is not useful in asympt omatic patients undergoing low risk procedures [16]. Similarly, the European Society of Cardiology 2009 preoperative guidelines do not recommend ECG in patients without risk factor s [52]. The 2007 ACC/AHA guidelines do recommend a preoperative resting 12-lead ECG for selected patients as follows (table 7):

Patients with at least one clinical risk factor scheduled to undergo vascular su

gery. These clinical risk factors are ischemic heart disease, compensated or prior hear t failure, cerebrovascular disease, diabetes, and renal insufficiency.

Patients scheduled to undergo intermediate-risk surgery with known cardiovascula disease, peripheral arterial disease, or cerebrovascular disease. The ACC/AHA gave a less strong recommendation to perform an ECG for patients sche duled to undergo vascular surgery with no clinical risk factors OR those scheduled to u ndergo intermediate-risk surgery with at least one clinical risk factor. It is uncertain whether the preoperative approach to obese patients should differ from that of the general population in regard to ECGs. The AHA 2009 scientific advisory on cardiovascular evaluation and management of severely obese patients (BMI 40 kg/m2) undergoing surgery states that an ECG is reasonable in all obese patients with at least one risk factor for coronary heart disease (diabetes, smoking, hypertension, or hyper lipidemia) or poor exercise tolerance [53]. However, we do not suggest routine ECGs as there is no evidence to show that preoperative ECGs in patients with severe obesity influence management or affect health outcomes. CHEST RADIOGRAPH Preoperative chest x-rays add little to the clinical evaluation in identifying patients at risk for perioperative complications [32]. Abnormal findi ngs on chest x-ray occur frequently, and are more prevalent in older patients. Several systema tic reviews and independent advisory organizations in the US and Europe recommend aga inst routine chest radiograph in healthy patients [54-57]. There is little evidence to support the use of a preoperative chest radiograph re gardless of age unless there is known or suspected cardiopulmonary disease from the history o r physical examination. In a meta-analysis of 21 studies of routine chest radiograp hy, among a total of 14,390 routine chest x-rays, there were 1444 abnormal studies [58]. On ly 140 abnormal findings were unexpected, and only 14 (0.1 percent) of all routine chest x-rays influenced management. One study screened 905 surgical admissions for the presence of clinical factors t hat were thought to be risk factors for an abnormal preoperative chest x-ray [59]. The ris k factors included age over 60 years, or clinical findings consistent with cardiac or pulmo nary

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1/22/2010 Preoperative medical evaluation of the healthy patient disease. No risk factors were evident in 368 patients; of these, only one (0.3 pe rcent) had an abnormal chest x-ray, which did not affect the surgery. On the other hand, 504 patients had identifiable risk factors; of these, 114 (22 percent) had significant abnorma lities on preoperative chest x-ray. While routine preoperative chest x-rays are not indicated, we agree with the Amer ican College of Physicians (ACP) recommendation for chest x-rays in patients with cardiopulmonary disease and those older than 50 years of age who are undergoing abdominal aortic aneurysm surgery or upper abdominal/thoracic surgery [11]. Posteroanterior and lateral chest x-ray is also suggested by the American Heart A ssociation for patients with severe obesity (BMI 40 kg/m2) [53]. In these patients, the chest radiograph may indicate undiagnosed heart failure, cardiac chamber enlargement, o r abnormal pulmonary vascularity suggestive of pulmonary hypertension, warranting f urther cardiovascular investigation. The relationship between findings on chest x-ray an d perioperative morbidity are not well defined in these populations, however, and s tudies are not available that indicate that preoperative radiography changes perioperative o utcomes. Thus, we do not suggest routine chest x-rays in severely obese patients. PULMONARY FUNCTION TESTS Routine pulmonary function tests are NOT indicated for healthy patients prior to surgery (see "Evaluation of preoperative pulmonary risk"). These tests generally should be reserved for patients who have dyspnea that remai ns unexplained after careful clinical evaluation. Clinical findings are more predict ive of the risk of postoperative pulmonary complication than are spirometric results [60]. These findings include decreased breath sounds, prolonged expiratory phase, rales, rhonchi, or w heezes. SUMMARY AND RECOMMENDATIONS The overall risk of surgery is low in healthy individuals. Preoperative tests usually lead to false positive results, unnecessa ry costs, and a potential delay of surgery. Preoperative tests should not be performed unless t here is a clear clinical indication.

A simple screening questionnaire can be helpful in the preoperative evaluation ( able 4). Important potential risk factors to discuss with the patient include age, exercis e capacity, and medication use. Obesity is not a risk factor for most major adverse postopera tive outcomes in patients undergoing noncardiac surgery. (See 'Clinical evaluation' ab ove.)

Routine preoperative laboratory tests have not been shown to improve patient outcomes among healthy patients undergoing surgery. In addition, routine testing in healthy patients has poor predictive value, leading to false positive test result s and/or increased medicolegal risk for not following up on abnormal test results (see 'Ra tionale for selective testing' above). We suggest baseline hemoglobin measurement for all patients 65 years of age or ol der who are undergoing major surgery and for younger patients undergoing surgery that is expected to result in significant blood loss (Grade 2C). For other healthy patien ts, we suggest NOT performing routine hemoglobin, white blood count, or platelet measure ments (Grade 2B). (See 'Complete blood count' above.) In the revised cardiac risk index, a serum creatinine >2.0 mg/dL (177 mol/L) predicted postoperative cardiac complications. We suggest NOT obtaining a serum creatinine concentration, except in the following patients (Grade 2B) (see 'Renal

http://www.uptodate.com/online/content/topic.do?topicKey=med_cons/6474&view=print 1/22/2010 Preoperative medical evaluation of the healthy patient function' above: - Patients over the age of 50 undergoing intermediate or high risk surgery.

- Younger patients suspected of having renal disease, when hypotension is like during surgery, or when nephrotoxic medications will be used. We suggest NOT testing for serum electrolytes, blood glucose, liver function, hemostasis, or urinalysis in the healthy preoperative patient (Grade 2B). (See 'L aboratory studies' above.) We suggest NOT ordering an ECG for asymptomatic patients undergoing low risk surgical procedures (Grade 2B). In accord with the 2007 ACC/AHA guidelines, we su ggest a 12-lead ECG in patients without perioperative clinical risk factor who require vascular surgical procedures (Grade 2C). In addition, a 12-lead ECG is part of the evaluat ion in patients with preexisting cardiovascular disease who are undergoing surgery. This is discussed in detail elsewhere. (See "Estimation of cardiac risk prior to noncardi ac surgery", section on 'Resting electrocardiogram' and 'Electrocardiogram' above.) ry function tests in the healthy patient (Grade 2B). We suggest obtaining a preopera tive

We suggest that clinicians NOT order routine preoperative chest x-rays or pulmon

chest x-ray in patients with cardiopulmonary disease and those older than 50 year s of age who are undergoing abdominal aortic aneurysm surgery or upper abdominal/thoracic surgery (Grade 2C). (See 'Chest radiograph' above and 'Pulmonary function tests' above.)

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tests. Ann Intern Med 1990; 113:969. 31. Macpherson, DS. Preoperative laboratory testing: Should any tests be "routine " before surgery? Med Clin North Am 1993; 77:289. 32. Garcia-Miguel, FJ, Serrano-Aguilar, PG, Lopez-Bastida, J. Preoperative assess ment. Lancet 2003; 362:1749. 33. Wu, WC, Schifftner, TL, Henderson, WG, et al. Preoperative hematocrit levels and postoperative outcomes in older patients undergoing noncardiac surgery. JAMA 200 ; 297:2481. 34. Bushick, JB, Eisenberg, JM, Kinman, J, et al. Pursuit of abnormal coagulation screening tests generates modest hidden preoperative costs. J Gen Intern Med 1989; 4:493. 35. Velanovich, V. The Value of Routine Preoperative Laboratory Testing in Predic ting Postoperative Complications: A Multivariate Analysis. Surgery 1991; 109:236. 36. Lee, TH, Marcantonio, ER, Mangione, CM, et al. Derivation and prospective val idation of a simple index for prediction of cardiac risk of major noncardiac surgery. Ci culation 1999; 100:1043. 37. Mathew, A, Devereaux, PJ, O'Hare, A, et al. Chronic kidney disease and postop erative mortality: a systematic review and meta-analysis. Kidney Int 2008; 73:1069. 38. Eagle, KA, Coley, CM, Newell, JB, et al. Combining clinical and thallium data optimizes preoperative assessment of cardiac risk before major vascular surgery. Ann Inter Med 1989; 110:859. 39. Higgins, T, Estafanous, F, Loop, F, et al. Stratification of morbidity and mo rtality outcome of preoperative risk factors in coronary artery bypass patients. JAMA 19 2; 267:2344. 40. Powell-Jackson, P, Greenway, B, Williams, R. Adverse effects of exploratory laparotomy in patients with unsuspected liver disease. Br J Surg 1982; 69:449. 41. Suchman, AL, Mushlin, AI. How well does the activated partial thromboplastin time predict postoperative hemorrhage? JAMA 1986; 256:750. 42. Sie, P, Steib, A. Central laboratory and point of care assessment of perioper ative hemostasis. Can J Anaesth 2006; 53:S12. 43. Rodgers, RP, Levin, J. A critical reappraisal of the bleeding time. Semin Thr omb Hemost 1990; 16:1. 44. Peterson, P, Hayes, TE, Arkin, CF, et al. The preoperative bleeding time test lacks clinical benefit: College of American Pathologists' and American Society of Clin cal Pathologists' position article. Arch Surg 1998; 133:134. 45. Koulouvaris, P, Sculco, P, Finerty, E, et al. Relationship between perioperat ive urinary tract infection and deep infection after joint arthroplasty. Clin Orthop Relat R s 2009; 467:1859.

46. David, TS, Vrahas, MS. Perioperative lower urinary tract infections and deep sepsis in patients undergoing total joint arthroplasty. J Am Acad Orthop Surg 2000; 8:66. 47. Lawrence, VA, Kroenke, K. The unproven utility of preoperative urinalysis. Ar ch Intern Med 1988; 148:1370. 48. Ollivere, BJ, Ellahee, N, Logan, K, et al. Asymptomatic urinary tract colonis ation predisposes to superficial wound infection in elective orthopaedic surgery. Int rthop 2009; 33:847. 49. Lawrence, VA, Kroenke, K. The unproven utility of the preoperative urinalysis : Economic evaluation. J Clin Epidemiol 1989; 42:1185.

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50. Goldberger, AL, O'Konski, M. Utility of the routine electrocardiogram before surgery and on general hospital admission. Ann Intern Med 1986; 105:552. 51. Liu, LL, Dzankic, S, Leung, JM. Preoperative electrocardiogram abnormalities do not predict postoperative cardiac complications in geriatric surgical patients. J Am Geriatr Soc 2002; 50:1186. 52. Poldermans, D, Bax, JJ, Boersma, E, et al. Guidelines for pre-operative cardi ac risk assessment and perioperative cardiac management in non-cardiac surgery: the Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) an endorsed by the European Society of Anaesthesiology (ESA). Eur Heart J 2009; 30:2769. 53. Poirier, P, Alpert, MA, Fleisher, LA, et al. Cardiovascular evaluation and ma nagement of severely obese patients undergoing surgery: a science advisory from the Ameri an Heart Association. Circulation 2009; 120:86. 54. The Swedish Council on Technology Assessment in Health Care (SBU). Preoperati ve routines. Stockholm: SBU, 1989. 55. Agence Nationale pour le Development de l'Evaluation Medicale (ANDEM). Indica tion of Preoperative Tests. Paris: ANDEM, 1992. 56. Guidelines and Protocols Advisory Committee (GPAC), Medical Services Commissi on, and British Columbia Medical Association. Guideline for Routine Pre-Operative Te ting. Victoria BC: Ministry of Health, 2000. 57. National Institute for Clinical Excellence (2003) Guidance on the use of preo perative tests for elective surgery. NICE Clinical Guideline No 3. London: National Insti ute for Clinical Excellence, 2003. 58. Archer, C, Levy, AR, McGregor, M. Value of routine preoperative chest x-rays: a meta-

analysis. Can J Anaesth 1993; 40:1022. 59. Rucker, L, Frye, EB, Staten, MA. Usefulness of screening chest roentgenograms in preoperative patients. JAMA 1983; 250:3209. 60. Lawrence, VA, Dhanda, R, Hilsenbeck, SG, et al. Risk of pulmonary complicatio ns after abdominal surgery. Chest 1996; 110:744.

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GRAPHICS

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Probability of an abnormal screening test result Number of independent tests 1 2 4 6 10 20 50

Prob

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Predictive value of positive test results Prevalence of disease, percent 0.1

Predictive valu

1.0 2.0 5.0 50.0

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Value of preoperative tests in influencing preoperative management and predicting postoperative complications Incidence of abnormalities that influence management, percent 0.1 0.0 0.0 0.0 0.1 0.0 0.0 0.0

Test Hemoglobin White blood cell count Platelet count Prothrombin time (PT) Partial thromboplastin time (PTT) Electrolytes Renal function Glucose Liver function tests Urinalysis Electrocardiogram Chest radiograph 2.6 3.0 0.1 1.4 1.8 2.6 0.5

4.3 3.3

NA**

1 1.6 2.5

*Although the LR+ value is higher for electrolytes than for other preoperative tests, most of these patients could have been selectively identified as candidates for testing based on clinical criteria. The authors

therefore do not recommend routine measurement of preoperative electrolytes. **NA = Not available; no studies have reported the incidence of adverse events in a cohort of healthy patients with normal or abnormal liver function tests. Reproduced with permission from Smetana, GW, Macpherson, DS. The case against routine preoperative laboratory testing. Med Clin North Am 2003; 87: 7. Copyright 2003 Elsevier Science.

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Preoperative medical evaluation questions for a healthy patient

Questions 1. Do you usually get chest pain or breathlessness when you climb up two of stairs at normal speed? 2. Do you have kidney disease?

3. Has anyone in your family (blood relatives) had a problem following a anaesthetic? 4. Have you ever had a heart attack? 5. Have you ever been diagnosed with an irregular heartbeat? 6. Have you ever had a stroke?

7. If you have been put to sleep for an operation were there any anaesth problems? 8. Do you suffer from epilepsy or seizures? ? 10. Do you have thyroid disease? 11. Do you suffer from angina? 12. Do you have liver disease? 13. Have you ever been diagnosed with heart failure? 14. Do you suffer from asthma? 15. Do you have diabetes that requires insulin? 16. Do you have diabetes that requires tablets only? 17. Do you suffer from bronchitis?

9. Do you have any problems with pain, stiffness or arthritis in your ne

Data from: Hilditch, WG, Asbury, AJ, Jack, E, McGrane, S. Validation of a pre-ana esthetic screening questionnaire. Anaesthesia 2003; 58:874.

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ASA physical status classification system ASA class 1 Physical status Healthy, no disease outside surgical process

Functional status Can walk up one flight of stairs or two level city blocks without distress Little or no a

Mild to moderate systemic disease, medically well controlled, with no functional limitation

Can walk up one flight of stairs or two level city blocks but will have to stop after completion of the exercise because of distress ASA I with ext anxiety and fe respiratory condition, pregnancy or active allergi

Severe systemic disease that results in functional limitation

Can walk up one flight of stairs or two level city blocks but will have to stop enroute becaus distress

Severe incapacitating disease process that is a constant threat to life

Unable to walk up one flight of stairs or two level city blocks. Distress is present even at rest.

Moribund patient not expected to survive 24 hours without an operation

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A declared brain-dead patient being maintained for harvesting of organs Suffix to indicate emergency surgery for any class

Any patient in Otherw whom an emergency operation is required

Adapted from: Cohen, MM, Duncan, PG, Tate, RB. Does anesthesia contribute to operative mortality? JAMA 1988; 260:2859; Malamed, S. Medical Emergencies in the Dental Office, Mosby 2007; Fehrenbach, MJ. ASA Physical Status Classification Sys tem: http://www.dhed.net/ASA%20Physical%20Status%20Classification%20SYSTEM.htm.

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ACC/AHA guideline summary: Cardiac risk stratification for noncardiac surgical procedures High risk (reported risk of cardiac death or nonfatal myocardial infarction [MI] often) Aortic and other major vascular surgery Peripheral arterial surgery

Intermediate risk (reported risk of cardiac death or nonfatal MI generally 1 to 5 percent) Carotid endarterectomy Head and neck surgery Intraperitoneal and intrathoracic surgery Orthopedic surgery Prostate surgery Low risk* (reported risk of cardiac death or nonfatal MI generally less than 1 percent) Ambulatory surgery Endoscopic procedures Superficial procedure Cataract surgery Breast surgery * Do not generally require further preoperative cardiac testing. Data from Fleish er, LA, Beckman, JA, Brown, KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the Americ an College of Cardiology/American Heart Association Task Force on Practice Guideline s (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American S ociety of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society , Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiograp hy and Interventions, Society for Vascular Medicine and Biology, and Society for Vascula r Surgery. J Am Coll Cardiol 2007; 50:e159.

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ACC/AHA guideline summary: Preoperative 12-lead rest electrocardiogram (ECG) prior to noncardiac surgery

Class I - There is evidence and/or general agreement that a preoperative rest ECG should be obtained in the following setting Patients with a least one clinical risk factor who require vascular su edures

 Patients with atherosclerotic cardiovascular disease scheduled for int isk procedures

Class IIa - The evidence or opinion is in favor of usefulness of a preoperative rest ECG in the following setting Patients with no clinical risk factors who require vascular surgical p

Class IIb - The evidence or opinion is less well established for the usefulness of a preoperative rest ECG in the following settings Patients with at least one clinical risk factor scheduled to undergo i -risk procedures

Class III - There is evidence and/or general agreement that preoperative rest and postoperative ECGs are not useful in the following setting Asymptomatic patients who are scheduled for a low-risk operative proce Data from Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE , Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Orn ato JP, Page RL, Riegel B, Tarkington LG, Yancy CW; American College of Cardiology; Ameri can Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery ); American Society of Echocardiography; American Society of Nuclear Cardiology; Hea rt Rhythm Society; Society of Cardiovascular Anesthesiologists; Society for Cardiova scular Angiography and Interventions; Society for Vascular Medicine and Biology; Society for Vascular Surgery. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 20 02 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) dev eloped in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiolog ists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Me dicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol. 2007 Oct 23;50(17):e159-241.

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