10. Preoperative medical evaluation

Question 1

Describe HX: Preoperative medical evaluation (4)

Answer 1

• A careful Hx is needed to identify cardiovascular, cerebrovascular, pulmonary, renal, or endocrine disease.
• Prior surgeries should also be noted along with tobacco, alcohol, and drug consumption.
• Personal or familial Hx of adverse reaction to anesthetic should be noted.
• All prescribed and over-the-counter medications, including herbal supplements, should be listed.

Question 2

Describe physical exam: Preoperative medical evaluation (2)

Answer 2

• A complete systems-based exam is required to identify signs of disease.
• Signs of cardiovascular, cerebrovascular, or pulmonary compromise should be further investigated with appropriate tests.

Question 3

Describe investigations: Preoperative medical evaluation (11)

Answer 3

• CBC: any patient with a Hx of anemia or blood loss or any procedure where > 500 mL blood loss is expected
• Group and screen/type and cross: not needed in low-risk procedures (e.g., breast lumpectomy) where minimal blood loss (< 500 mL) is expected
• Electrolytes, creatinine, and liver function tests:
  
  • Any patient with a Hx of renal or hepatopancreatic disease.
  • Any diabetic patient.
  • Any procedure with a significant amount of blood loss (> 500 mL) or where the use of contrast dye is projected (e.g., angiography).
• Blood sugar: any patient with Hx of diabetes
• Coagulation profile:
  
  • Any patient with a Hx of bleeding or hepatic disease.
  • If patient is on anticoagulation therapy (e.g., patient with a Hx of deep vein thrombosis) and had been instructed to discontinue the therapy, then recheck coagulation profile on morning of surgery
• Urinalysis: Any patient with dysuria. All operations with planned prosthesis.
• Pregnancy test: All menstruating female patients
• Chest x-ray: Any Hx of cardiovascular or pulmonary disease should have a chest x-ray arranged within 2 wk of surgery, both to assess preoperative function and to provide a reference should the patient’s postoperative course deteriorate
• Electrocardiogram: Needed for preoperative patients > 50 y.o. and selected patients with known Hx of cardiac disease < 50 y.o.
• Echocardiogram: patients with a Hx of heart failure and patients scheduled to undergo heart or major vessel vascular surgery
• Pulmonary function tests: patients with a Hx of pulmonary disease and any patients scheduled to undergo thoracic surgery

Question 4

Describe: Cardiac evaluation (Figure)

Answer 4

Question 5

Before surgery, what to do with patients with newly diagnosed pathology? (1)

Answer 5

Any newly diagnosed pathology should be promptly managed and optimized prior to surgery.

Question 6

Before surgery, what to do with patients with uncontrolled conditions such as hypertension, congestive heart failure, sleep apnea, or diabetes? (1)

Answer 6

should be medically optimized prior to surgery.

Question 7

Before surgery, what to do with patients with medications? (3)

Answer 7

Patients should continue preoperative medications up to the day of the operation, with the exception of

• anticoagulants (e.g., warfarin)
• antiplatelets (e.g., aspirin)
• antihyperglycemics (e.g., metformin)

which should be stopped in coordination with anesthesia.

Question 8

Before surgery, what to do with patients on oral steroids? (1)

Answer 8

should be transitioned to an intravenous dose for the im- mediate pre- and postoperative period.