Preoperative medical evaluation of the healthy patient

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Official reprint from UpToDate www.uptodate.com 2010 UpToDate

Preoperative medical evaluation of the healthy patient

Author Gerald W Smetana, MD Section Editor Mark D Aronson, MD Deputy Editor Pracha Eamranond, MD, MPH | This topic last updated: May 18,

Last literature review version 18.2: May 2010 2010

INTRODUCTION Clinicians are often asked to evaluate a patient prior to surgery. The medical consultant may be seeing the patient at the request of the surgeon, or may 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. Preoperative assessments for specific systems issues and surgical procedures are discussed separately (see "Estimation of cardiac risk prior to noncardiac surgery" and see topics on specific conditions). RATIONALE FOR SELECTIVE TESTING The prevalence of unrecognized disease that impacts upon surgical risk is low in healthy individuals. Nevertheless, clinicians often perform laboratory tests in this group of patients out of habit and medicolegal concern, with little benefit and a high incidence of false positive results. Representative studies that have addressed this issue include: In a trial of 1061 ambulatory surgical patients randomly assigned to preoperative 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 receive 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 many institutions, guidelines still require routine laboratory testing despite compelling evidence showing no benefit of such testing. A systematic review of three randomized trials of testing versus no testing in a total of 21,531 cataract surgeries found that adverse events did not differ between the two groups [2]. Institutions may safely eliminate a requirement for routine laboratory tests before cataract surgery. In a retrospective study of 2000 patients undergoing elective surgery, 60 percent of routinely ordered tests would not have been performed if testing had only been done for recognizable indications; only 0.22 percent of these revealed abnormalities that might influence perioperative management [3]. Further chart review determined that these abnormalities were not acted upon, nor did they have adverse surgical consequences.

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One report found that only ten routine laboratory test results in 3782 patients required treatment; just one of these required pharmacologic treatment [4]. In a second review of 5003 preoperative screening tests in 2570 patients, only 104 tests were abnormal and potentially significant [5]. Screening modified preoperative management in only four patients. Predictive value There are several arguments for avoiding routine preoperative tests. 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 independent tests in a patient with no disease will yield at least one abnormal result 64 percent of the time (table 1). Thus, the predictive value of abnormal test results is low in healthy patients with a low prevalence of disease (table 2). Aside from possibly causing patient alarm, the additional testing prompted by false positive screening tests leads to unnecessary costs, risks, and a potential delay of surgery. In addition, clinicians often fail to act upon abnormal test results from routine preoperative testing, thereby creating an additional medicolegal risk. 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 likelihood ratios for a postoperative complication (table 3) [6]. For nearly all potential laboratory studies, a normal test did not substantially reduce the likelihood of a postoperative 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, and electrolytes); however, clinical evaluation can predict most patients with an abnormal result. This was illustrated by the low incidence of a change in preoperative management 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 performed evaluations is limited. Screening questionnaire Screening questions appear on many standard institutional preoperative evaluation forms. One validated screening instrument, derived from 100 patients, comprises 17 questions that allowed nurses to identify those patients who 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 conditions 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 to noncardiac surgery".) Some studies found a small increased risk of surgery associated with advancing age [8,9]. In a review of 50,000 elderly patients, for example, the risk of mortality with elective surgery increased from 1.3 percent for those under 60 years of age, to 11.3 percent in the 80 to 89 year-old age group [9]. Among 1.2 million Medicare patients undergoing elective surgery, mortality risk increased linearly with age for most surgical procedures [10].

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Operative mortality for patients 80 years and older was more than twice that of patients 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 pulmonary complications. Age was one of the most important patient-related predictors of pulmonary 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 rates 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 Anesthesiologists (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 different than the actuarial survival in matched patients not undergoing surgery [12]. A larger study of 4315 patients also found a higher perioperative complication and mortality rate in older individuals, but the mortality rate was low [13]. Among 31 patients age 100 years and older undergoing surgery requiring anesthesia, perioperative and one-year mortality rates were similar to matched peers from the general population [14]. Much of the risk associated with age is due to increasing numbers of comorbidities that confer excess risk. After adjusting for comorbidities more common with age, the impact 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 part of the preoperative evaluation. Exercise capacity is an important determinant of overall perioperative risk; patients with virtually unlimited exercise tolerance generally 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 daily 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 patient 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 exercise capacity as the inability to either walk four blocks or climb two flights of stairs. Patients reporting poor exercise capacity had twice as many serious postoperative complications as those who reported good exercise capacity (20 versus 10 percent, respectively). There was also a significant difference in cardiovascular complications (10 versus 5 percent), but not for total pulmonary complications (9 versus 6 percent). Medication use A history of medication use should be obtained for all patients before surgery and should specifically include over-the-counter medications. Aspirin, ibuprofen, and other nonsteroidal anti-inflammatory drugs are readily available and are associated with an increased risk of perioperative bleeding. Specific inquiry about use of

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complementary and alternative medications should also be part of the preoperative assessment. A detailed discussion of perioperative medication management is presented 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 embolism. None of the published and widely disseminated cardiac risk indices include obesity as a risk factor for postoperative cardiac complications. However, in cardiac surgery, some studies have shown higher complication rates for obese patients, including increased hospital stay [19], wound infections [19,20], prolonged mechanical ventilation [20], and atrial arrhythmias [20,21]. Representative studies related to postoperative mortality in noncardiac surgery include: In a matched case control study of 1962 patients undergoing noncardiac surgery, obesity was not associated with increased mortality (1.1 percent in obese patients versus 1.2 percent in controls) [22]. In a large, multi-institutional, prospective cohort of 118,707 patients undergoing 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 that may be 'primed' to mount an appropriate inflammatory and immune response to the stress 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 complications [24-28]. Obesity is also not a risk factor for postoperative pulmonary conditions other than pulmonary embolism. In a review which found that the unadjusted relative risks for pulmonary complications due to obesity were 0.8 to 1.7, the incidence of pulmonary complications was 21 percent in both obese and non-obese patients [28]. In another systematic review, only one of eight eligible studies using multivariable analysis to adjust for confounders found that obesity was a predictor of postoperative pulmonary risk [11]. The one exception to the observation that obesity does not increase the risk of noncardiac surgery is venous thromboembolism. Obesity is a major risk factor for postoperative deep venous thrombosis and pulmonary embolism. (See "Prevention of venous thromboembolic disease in surgical patients".) LABORATORY EVALUATION Preoperative routine laboratory investigations are now minimized; these checks should have been adapted to the circumstances of each patient. The National Institute for Clinical Excellence guidelines and have made the most of the hospitals have a version of this on their own guidelines. The following things is what should be used as guidance. [29].

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7549 preoperative tests performed in 1109 patients undergoing elective surgery [30]. The tests were duplicates of those performed within the year prior to surgery in 47 percent of cases: Of 3096 previous results that were normal (as defined by hospital reference range) 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. Most of these abnormalities were predictable from the patient's history, and most were not noted in the medical record. In contrast, of 461 previous tests that were abnormal, 78 (17 percent) repeat values at admission were outside a range considered acceptable for surgery, suggesting that tests that have recently been abnormal should be repeated preoperatively. Hemoglobin Healthy patients who will be undergoing elective surgery with an estimated blood loss of <10% of total blood volume does not require an assessment of hemoglobin. Hemoglobin assessment is needed on: [34]. Neonates <6 months Women> 50 years Men> 65 years Sickle Cell Disease malignancies haematological abnormalities Loss of preoperative blood Trauma Malnutrition other systemic diseases and ASA 3 or above

Ureum and electrolyte Not indicated in healthy patients undergoing elective surgery. indicated on [35].

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.

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Patients> 65 years Kidney Disease Diabetes Hypertension Ischemic heart disease / vascular Liver disease Patients in the treatment of digoxin, diuretics, steroids, ACE inhibitors, and antiarrhythmic agents. [38,39]

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 patients had unexpected elevations in preoperative serum glucose; only one of these patients developed significant postoperative hyperglycemia and this was not recognized until after total 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 healthy patients. 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".) The prevalence of abnormal ECGs increases with age [50]. Important ECG abnormalities 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 baseline to compare with postoperative ECG abnormalities. The 2007 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines on Perioperative Cardiovascular Evaluation state that ECG is not useful in asymptomatic patients undergoing low risk procedures [16]. Similarly, the European Society of Cardiology 2009 preoperative guidelines do not recommend ECG in patients without risk factors [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 surgery. These clinical risk factors are ischemic heart disease, compensated or prior heart failure, cerebrovascular disease, diabetes, and renal insufficiency. Patients scheduled to undergo intermediate-risk surgery with known cardiovascular disease, peripheral arterial disease, or cerebrovascular disease. The ACC/AHA gave a less strong recommendation to perform an ECG for patients scheduled to undergo vascular surgery with no clinical risk factors OR those scheduled to undergo intermediate-risk surgery with at least one clinical risk factor.

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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 hyperlipidemia) 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 findings on chest x-ray occur frequently, and are more prevalent in older patients. Several systematic reviews and independent advisory organizations in the US and Europe recommend against routine chest radiograph in healthy patients [54-57]. There is little evidence to support the use of a preoperative chest radiograph regardless of age unless there is known or suspected cardiopulmonary disease from the history or physical examination. In a meta-analysis of 21 studies of routine chest radiography, among a total of 14,390 routine chest x-rays, there were 1444 abnormal studies [58]. Only 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 that were thought to be risk factors for an abnormal preoperative chest x-ray [59]. The risk factors included age over 60 years, or clinical findings consistent with cardiac or pulmonary Other tests may be required for a full assessment against a dangerous disease, the effectiveness of a treatment, and whether the patient is in optimal medical condition and other risks that exist in the patient. The investigation may include: Pulmonary Function Test Blood Gas Analysis (pulmonary disease with limited exercise tolerance) echocardiography (heart disease with an indication of the limited functionality) ECG (coronary artery disease with angina) Liver enzymes (to alcoholism, liver disease) Blood Sugar (Diabetes) Endocrine Function (hypo / hyperthyroidism) Some checks are also necessary as a basis for comparing preoperative and postoperative intra (eg Blood Gas Analysis).

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Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Chung, F, Yuan, H, Yin, L, et al. Elimination of preoperative testing in ambulatory surgery. Anesth Analg 2009; 108:467. 2. Keay, L, Lindsley, K, Tielsch, J, et al. Routine preoperative medical testing for cataract surgery. Cochrane Database Syst Rev 2009; :CD007293. 3. Kaplan, EB, Sheiner, LB, Boeckmann, MS, et al. The Usefulness of Preoperative Laboratory Screening. JAMA 1985; 253:3576. 4. Narr, BJ, Hansen, TR, Warner, MA. Preoperative laboratory screening in healthy Mayo patients: Cost-effective elimination of tests and unchanged outcomes. Mayo Clin Proc 1991; 66:155. 5. Turnbull, JM, Buck, C. The value of preoperative screening investigations in otherwise healthy individuals. Arch Intern Med 1987; 147:1101. 6. Smetana, GW, Macpherson, DS. The case against routine preoperative laboratory testing. Med Clin North Am 2003; 87:7. 7. Hilditch, WG, Asbury, AJ, Jack, E, McGrane, S. Validation of a pre-anaesthetic screening questionnaire. Anaesthesia 2003; 58:874. 8. Goldman, L, Caldera, D, Nussbaum, S, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 1977; 297:845. 9. Linn, BS, Linn, MW, Wallen, N. Evaluation of results of surgical procedures in the

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Preoperative medical evaluation of the healthy patient

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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 cardiac 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) and 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 management of severely obese patients undergoing surgery: a science advisory from the American Heart Association. Circulation 2009; 120:86. 54. The Swedish Council on Technology Assessment in Health Care (SBU). Preoperative routines. Stockholm: SBU, 1989. 55. Agence Nationale pour le Development de l'Evaluation Medicale (ANDEM). Indication of Preoperative Tests. Paris: ANDEM, 1992. 56. Guidelines and Protocols Advisory Committee (GPAC), Medical Services Commission, and British Columbia Medical Association. Guideline for Routine Pre-Operative Testing. Victoria BC: Ministry of Health, 2000. 57. National Institute for Clinical Excellence (2003) Guidance on the use of preoperative tests for elective surgery. NICE Clinical Guideline No 3. London: National Institute for Clinical Excellence, 2003. 58. Archer, C, Levy, AR, McGregor, M. Value of routine preoperative chest x-rays: a metaanalysis. 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 complications after abdominal surgery. Chest 1996; 110:744.