The preoperative management of any patient is part of a continuum of care that extends from the surgeon’s initial consultation through the patient’s full recovery. While this ideally involves a multidisciplinary collaboration, surgeons lead the effort to assure that correct care is provided to all patients. This involves the establishment of a culture of quality care and patient safety with high, uniform standards. In addition, the surgeon is responsible for balancing the hazards of the natural history of the condition if left untreated versus the risks of an operation. A successful operation depends upon the surgeon’s comprehension of the biology of the patient’s disease and keen patient selection.

This chapter will consider preoperative preparation from the perspectives of the patient, the operating room facility and equipment, the operating room staff, and the surgeon.

History & Physical Examination

The surgeon and team should obtain a proper history from each patient. The history of present illness includes details about the presenting condition, including establishing the acuity, urgency, or chronic nature of the problem. Inquiries will certainly focus on the specific disease and related organ system. Questions regarding pain can be guided by the acronym OPQRST, relating to Onset (sudden or gradual), Precipitant (eg, fatty foods, movement, etc), Quality (eg, sharp, dull, or cramps), Radiation (eg, to the back or shoulder), Stop (what offers relief?), and Temporal (eg, duration, frequency, crescendo-decrescendo, etc). The presence of fevers, sweats, or chills suggests the possibility of an acute infection, whereas significant weight loss may imply a chronic condition such as a tumor. The history of present illness is not necessarily confined to the patient interview. Family members or guardians provide useful information, and outside records can be indispensable. Documents might include recent laboratory or imaging results that preclude the need for repetitive, costly testing. The surgeon should request CD-ROM disks of outside imaging, if appropriate. In the case of reoperative surgery, prior operative reports and pathology reports are essential (eg, when searching for a missing adenoma in recurrent primary hyperparathyroidism).

The past medical history should include prior operations, especially when germane to the current situation, medical conditions, prior venous thromboembolism (VTE) events such as deep vein thromboses (DVT) or pulmonary emboli (PE), bleeding diatheses, prolonged bleeding with prior operations or modest injuries (eg, epistaxis, gingival bleeding, or ecchymoses), and untoward events during surgery or anesthesia, including airway problems. One must secure a list of active medications, with dosages and schedule. Moreover, it is beneficial to inquire about corticosteroid usage within the past 6 months, even if not current, to avoid perioperative adrenal insufficiency. Medication allergies and adverse reactions should be elicited, although knowledge about environmental and food allergies is also valuable and should be recorded so that these exposures are avoided during the hospital stay. Some anesthesiologists are reluctant to use propofol in patients with egg allergies, and reactions to shellfish suggest the possibility of intolerance of intravenous iodinated contrast agents.

The social history classically involves inquiries into tobacco, alcohol, and illicit drug usage, but this moment also offers the opportunity to establish a personal relationship with patients (and their loved ones). It is fun and often stimulating to learn about patients’ occupations, avocations, exercise, interests and accomplishments, fears and expectations, and family lives. Patients’ regular activities offer insight into physiologic reserve; an elite athlete should tolerate nearly any major operation, whereas a frail, sedentary patient can be a poor candidate for even relatively minor operations.

A family history includes queries pertinent to the patient’s presenting condition. For example, if a patient with a colorectal cancer has relatives with similar or other malignancies, genetic conditions such as familial adenomatous polyposis or hereditary nonpolyposis colorectal cancer could be indicted. This scenario would have screening implications for both the patient and family members. In addition, one should also elicit a family history of VTE complications, bleeding disorders, and anesthesia complications. For example, a sudden and unexpected death of a relatively young family member during an operation could suggest the possibility of a pheochromocytoma, particularly in the setting of a medullary cancer or related endocrine disorder. A strong family history of allergic reactions might imply hypersensitivity to medications.

A review of systems assesses the patient’s cardiovascular, pulmonary, and neurologic status, including questions about exertional chest pain or dyspnea, palpitations, syncope, productive cough, or central nervous symptoms. It is also important to have a basic understanding of the patient’s symptoms relative to other major organ systems. For example, while one might not necessarily expect an orthopedic surgeon to have an interest in a patient’s gastrointestinal or genitourinary habits or problems, these issues may bear grave consequences if a patient experiences postoperative incontinence following joint replacement. Regardless of degree of specialization, surgeons and their designated teams are capable of identifying and investigating potentially confounding conditions.

A thorough physical examination is also an essential part of the patient assessment. Even if the surgeon already knows from imaging that there will be no pertinent physical findings, human touch and contact are fundamental to the development of a trusting physician-patient relationship. In addition to the traditional vital signs of pulse, blood pressure, respiratory rate, and temperature, for many operations it is also important to record the patient’s baseline oxygen saturation on room air, weight, height, and body mass index (BMI). The physical examination includes an assessment of general fitness, exercise tolerance, cachexia, or obesity, as well as focusing on the patient’s condition. Additional observations may detect findings such as cardiopulmonary abnormalities, bruits, absent peripheral pulses or bruits, adenopathy, skin integrity, incidental masses, hand dominance, neurologic deficits, or deformities. A thorough abdominal examination may include digital anorectal and pelvic examinations. The surgeon should also appreciate potential airway problems, particularly if general anesthesia is anticipated.

Preoperative Testing

Laboratory and imaging investigations are tailored to the individual patient’s presenting condition, as discussed in later chapters. However, there should be no “routine” battery of preoperative laboratory studies for all patients. In fact, published data do not support an association between routine studies and outcome. In addition, laboratory tests are costly and may result in harm due to false-positive and fortuitous findings. Instead, tests should be selected based upon the patient’s age, comorbidities, cardiac risk factors, medications, and general health, as well as the complexity of the underlying condition and proposed operation. For example, children uncommonly require preoperative laboratory tests for most operations. On the other hand, a complete blood count, chemistries, and an electrocardiogram are proper for high-risk patients before complex operations. Algorithms and grid matrices are available to individualize the selection of preoperative tests (Table 3–1). Importantly, each system should establish a practice for managing abnormal test results, whether germane to the patient’s active condition or a serendipitous finding.

A complete blood cell count and basic chemistries are reasonable for some operations, but their likelihood of predicting abnormal or meaningful results should be considered. Coagulation factors such as prothrombin time (PT), international normalized ratio (INR), and partial thromboplastin time (PTT) are not routinely indicated but should be pursued when patients report prolonged bleeding or the usage of anticoagulants. Moreover, INR and PTT may be warranted for operations that have little threshold for intraoperative or postoperative bleeding, such as those on the brain, spine, or neck. Bile duct obstruction, malnutrition, or an absent terminal ileum can affect vitamin K absorption, and a preoperative assessment of INR is important in those instances as well. A pregnancy test (eg, urine beta-human chorionic gonadotropin [beta-HCG]) should be performed shortly before surgery on women with childbearing potential. Other laboratory testing will be dictated by specific conditions, including liver chemistries, tumor markers, and hormone levels. A blood bank specimen should be selectively submitted in advance of operations that are associated with significant hemorrhage or in the setting of anemia with prospects for further blood loss. The preparation of blood for transfusion is costly, so blood-typing alone may suffice without actual cross-matching.

Routine preoperative testing of blood glucose is an intriguing concept, given the relationship between elevated blood sugars and surgical site infections (SSIs), although hemoglobin A_1C levels have not correlated with postoperative infections. Some reckon that nondiabetic patients comprise 30%-50% of cases with perioperative hyperglycemia, perhaps constituting an argument for measuring preoperative glucose levels in all candidates for major operations. While it is accepted that diabetic patients require close monitoring of perioperative glucose levels, including immediately before the operation, the value of doing this for all patients is evolving and warrants thoughtful investigation.

Some investigators have advocated routine nasal swab screening to identify carriers of Staphylococcus aureus. The results can guide decontamination measures such as intranasal application of antibiotic ointment (eg, mupirocin) and local hygiene with 2% chlorhexidine showers for 5 days before surgery. Patients with methicillin-resistant S aureus (MRSA) receive appropriate antibiotic prophylaxis and contact precautions. Although the issue of routine MRSA screening is not fully resolved, this practice may be ideal at least for immunocompromised patients and for those undergoing open cardiac operations and implantations of foreign bodies, particularly in orthopedics and neurosurgery. Prospective wound or abscess culture results should also influence decisions about perioperative antibiotics.

Electrocardiograms are not routinely performed but are justified for patients older than 50 years; those having vascular operations; and those with a history of hypertension, cardiac disease, significant respiratory disease, renal dysfunction, and diabetes mellitus. Chest radiographs are no longer performed on a regular basis but are primarily reserved for patients with malignancies or perhaps with significant pulmonary disease. Further special tests are selectively obtained when clinically indicated and often with guidance from consultants; these tests may include echocardiography, cardiac stress testing, baseline arterial blood gases, and pulmonary function tests. Carotid ultrasonography may be valuable in patients with carotid bruits or histories of cerebrovascular accidents or transient ischemia attacks. Noninvasive venous studies may be considered in patients who have had prolonged immobility and/or hospital stays before surgery.

At its simplest, the process of preparing a patient for an operation can involve a rapid assessment in the clinic or emergency room followed by an expeditious trip to the operating room. However, like most care in the contemporary health care system, the process is more commonly complex and involves a formal series of integrated steps to assure best outcomes. It is incumbent upon the surgery team to create an efficient and cost-effective preoperative system and scheduling protocol that result in optimally prepared patients, rare cancellations of operations, and few disruptions of the operating room schedule. A systemic approach to patient preparation focuses upon risk assessment and reduction, as well as education of the patient and family. This effort begins during the first encounter with the surgeon and continues through the moments before the operation. Ideal preoperative systems assign risk based upon evaluations that are derived from sound published evidence and best practices and driven by standardized algorithms to identify and then modify hazards before operations.

Risk Assessment & Reduction

Overview

The essence of preparing a patient for an operation regards considering whether the benefits of the operation justify the risks of doing harm, along with deciding how to minimize or eliminate those hazards. The American Society of Anesthesiologists (ASA) classification system (Table 3–2) stratifies the degree of perioperative risk for patients. While somewhat rudimentary, this system has faithfully served anesthesiologists and surgeons in predicting how well patients might tolerate operations, and the scores have been validated by several recent publications. The Acute Physiology and Chronic Health Evaluation (APACHE II and III) is an example of a severity of illness scoring system that may be applied to intensive care unit patients to predict mortality. The value of such assessments lies in numerically designating the severities of patients’ conditions, permitting comparisons of outcomes.

The University Health Systems Consortium (UHC) analyses derive from inpatient administrative and financial datasets to predict risk-adjusted outcomes for mortality, lengths of stay, and cost of care. The vagaries of medical coding can result in discrepancies, and the UHC system does not monitor patients after hospital discharge. Nevertheless, UHC data can identify deficiencies in practice. Although clinical databases are more costly and challenging to implement than commercially available products such as the UHC program, they provide more robust risk-adjusted outcomes data. Examples of clinical databases include those from the Society of Thoracic Surgeons (STS) and the National Surgical Quality Improvement Program (NSQIP). In NSQIP, dedicated nurses prospectively collect and validate an established panel of defined patient variables, comorbidities, and outcomes, and they pursue surveillance for 30 days after hospital discharge. The NSQIP analysis considers patient factors, effectiveness of care, and random variation, and logistic regression models calculate risk-adjusted 30-day morbidity and mortality. These data are reported as odds ratios for comparison with expected outcomes, allowing for the severity of the patients’ illnesses. Immediate benefits of NSQIP present the ability to identify true risk-adjusted data and local opportunities for improvement. For example, Veterans Administration (VA) surgeons reduced postoperative mortality from 3.2% in 2003 to 1.7% in 2005, while the complication rate declined from 17% to 10% (p < 0.0001). This effort focuses upon systems of care, providing reliable data to assess and reduce risks associated with operations. When compared to UHC, NSQIP is much more likely to identify complications because of its surveillance of patients 30 days beyond their hospitalizations.

The NSQIP program has also generated a tremendous repository of data to develop “risk calculators” for a variety of operations and conditions, allowing preoperative risk assessments and hopefully facilitating significant reductions of preoperative hazards. Finally, NSQIP participants have fostered a culture of sharing best practices and processes, both within the published literature and through formal and personal collaborations.

Beyond the obvious physical and emotional implications of adverse outcomes for patients and their families, the financial costs of postoperative complications to the health care system are staggering. It has been postulated that a major postoperative complication adds over $11,000 to the cost of the hospital care of an affected individual and significantly extends the duration of the inpatient confinement. In fact, the total cost of care increases by more than half when a complication develops. Notably, respiratory complications may increase the cost of care by more than $52,000 per patient. Strikingly, data from NSQIP have demonstrated that the occurrence of a serious complication (excluding superficial wound infections) after major operations is an independent risk factor for decreased long-term survival. Therefore, it is crucial that efforts focus upon reducing and eliminating postoperative complications.

Well-designed, systematic preoperative assessment programs can prospectively identify predictors of various complications and drive the ability to attenuate risks and improve outcomes. The perspective of teams of surgeons, physicians, nurses, and others with expertise managing standardized, algorithm-driven preoperative evaluations, often with checklists, is a departure from traditional care that primarily involved solitary surgeons with disparate practices. The new paradigm recognizes that variability in practice is the enemy of efficiency.

The financial dividends appreciated from enhanced results and diminished death and complication rates more than compensate for the expenditures associated with quality improvement efforts and participation in auditing programs such as NSQIP. It is essential that surgeons monitor their patients’ outcomes, preferably in a risk-adjusted fashion, to understand their practices and to demonstrate opportunities for improvement.

Cardiovascular

In 1977, Goldman published a multifactorial index for assessing cardiac hazards among patients undergoing noncardiac operations. The same group issued a Revised Cardiac Risk Index (RCRI) in 1999, reporting six independent predictors of cardiac complications. These include a history of ischemic heart disease, congestive heart failure, cerebrovascular disease, a high-risk operation, preoperative treatment with insulin, and a preoperative serum creatinine greater than 2.0 mg/dL. The likelihood of major cardiac complications increases incrementally with the number of factors present. Contemporary NSQIP data have led to the development of a risk calculator to predict postoperative cardiac complications. A multivariate logistic regression analysis demonstrated five prognostic factors for perioperative myocardial infarction (MI) or cardiac arrest: the type of operation, dependent functional status, abnormal creatinine, ASA class, and increasing age. The analysis has been validated and has led to the composition of an interactive risk calculator. Another multivariate model demonstrated criteria that predict adverse cardiac events among patients who have had elective vascular operations, and it also suggests improved predictive accuracy among these patients compared to the RCRI. Independent hazards include increasing age, smoking, insulin-dependent diabetes, coronary artery disease, congestive heart failure (CHF), abnormal cardiac stress test, long-term beta-blocker therapy, chronic obstructive pulmonary disease, and creatinine ≥1.8 mg/dL. Conversely, the analysis demonstrated a beneficial effect of prior cardiac revascularization. There is obviously overlap among the factors identified in these models.

The determination of an increased chance of a patient developing postoperative cardiac complications will certainly influence the tenor of preoperative discussions with patients and their family members, especially if the surgeon can present validated data regarding the actual likelihood of a cardiac complication or death. In addition, correctable hazards may be addressed, including smoking cessation, optimal control of diabetes, hypertension, and fluid status, and assurance of compliance with medical measures. Finally, formal risk assessments guide cardiologists with respect to cardiac stress testing, echocardiography, and coronary catheterization among higher-risk patients. Selected patients may be candidates for preoperative revascularization, either with coronary artery stent placement or surgical bypass.

The American College of Cardiology (ACC) Foundation and the American Heart Association (AHA) periodically issue joint recommendations about the cardiac evaluation and preparation of patients in advance of noncardiac operations. These guidelines are evidence based, include an explanation of the quality of the data, and provide comprehensive algorithms for the propriety of testing, medications, and revascularization to assure cardiac fitness for operations. As important as preoperative cardiac risk stratification is, a cardiology consultation also lays the groundwork for postoperative risk assessment and later modifications of coronary risk factors.

Noninvasive and invasive preoperative testing should be performed only when the results will influence patient care. Noninvasive stress testing before noncardiac operations is indicated in patients with active cardiac conditions (eg, unstable angina, recent MI, significant arrhythmias, or severe valvular disease), or in patients who require vascular operations and have clinical risk factors and poor functional capacity. Good data support coronary revascularization before noncardiac operations in patients who have significant left main coronary artery stenosis, stable angina with three-vessel coronary disease, stable angina with two-vessel disease and significant proximal left anterior descending coronary artery stenosis with either an ejection fraction < 50% or ischemia on noninvasive testing, high-risk unstable angina or non–ST-segment elevation MI, or acute ST-elevation MI. However, current data do not support routine preoperative percutaneous revascularization among patients with asymptomatic coronary ischemia or stable angina.

The role of beta-blockers for cardiac protection is evolving, and these agents are no longer empirically advised for all high-risk patients due to potential adverse consequences. Beta-blockers should be continued perioperatively among those patients who are already taking them and among those having vascular operations and at high cardiac risk, including known coronary heart disease or the presence of ischemia on preoperative testing. The role of beta-blockers is uncertain for patients with just a single clinical risk factor for coronary artery disease. Cardiac complication risk calculators may become beneficial in the stratification of patients who should receive beta-blockers to reduce perioperative cardiac complications.

Preoperative aspirin usage should continue among patients at moderate to high risk for coronary artery disease, unless the risk of resultant hemorrhage definitely outweighs the likelihood of an atherothrombotic event. Thienopyridines, such as ticlopidine or clopidogrel, are administered in concert with aspirin as dual antiplatelet therapy following placement of coronary artery stents. They are intended to inhibit platelet aggregation and resultant stent thrombosis, although they certainly increase the risk of hemorrhage. Therefore, if an operation can be anticipated, the surgeon and cardiologist must coordinate efforts regarding the sequence of the proposed operation and coronary stenting, weighing the hazards of operative bleeding while on antiplatelet therapy for a stent versus potential postoperative coronary ischemia. Elective operations with a significant risk of bleeding should be delayed 12 months before the discontinuation of the thienopyridine in the presence of a drug-eluting stent, at least 4-6 weeks for bare-metal stents, and 4 weeks after balloon angioplasty. Therefore, if a patient requires percutaneous coronary artery intervention prior to noncardiac surgery, bare-metal stents or balloon angioplasty should be employed rather than drug-eluting stents. Even when thienopyridines are withheld, aspirin should be continued, and the thienopyridine is to be resumed as soon as possible after the operation. In circumstances such as cardiovascular surgery, the dual antiplatelet agents are continued throughout the perioperative course to minimize the likelihood of vascular thrombosis.

Pulmonary

Postoperative pulmonary complications (PPC), such as the development of pneumonia and ventilator dependency, are debilitating and costly. They are associated with prolonged lengths of hospital stay, an increased likelihood of readmission, and increased 30-day mortality. Therefore, it is critical to identify patients at greatest risk for PPC. Established risk factors for PPC include advanced age, elevated ASA class, congestive heart failure, functional dependence, known chronic obstructive pulmonary disease, and perhaps malnutrition, alcohol abuse, and altered mental status. In addition, hazards are greater for certain operations (eg, aortic aneurysm repair, thoracic or abdominal, neurosurgery, head and neck, and vascular), prolonged or emergency operations, and those done under general anesthesia. A risk calculator was devised to predict the likelihood of PPC occurrence, indicating seven independent risk factors. These include low preoperative arterial oxygen saturation, recent acute respiratory infection, age, preoperative anemia, upper abdominal or thoracic operations, duration of operation over 2 hours, and emergency surgery.

A multivariable logistic regression has affirmed that active smoking is significantly associated with postoperative pneumonia, SSI, and death, when compared to nonsmokers or those who have quit smoking. Moreover, this is a dose-dependent phenomenon, predicated upon the volume and duration of tobacco consumption. The benefits of preoperative smoking cessation seem to be conferred after an interval of at least 4 weeks. Conversely, the risk of developing PPC is the same for current smokers versus those who quit smoking for less than 4 weeks before an operation. Smoking cessation also confers favorable effects on wound healing. Therefore, patients should be encouraged to stop smoking at least 1 month before operations, ideally with programmatic support through formal counseling programs and possibly smoking cessation aids such as varenicline or transdermal nicotine.

A recent analysis of patients having general surgery and orthopedic operations demonstrated that sleep apnea is an independent risk factor for the development of PPC. A simple “STOP BANG” questionnaire can screen patients for sleep apnea. The acronym queries Snoring, Tired during day, Obstructed breathing pattern during sleep, high blood Pressure, BMI, Age over 50 years, Neck circumference, and male Gender. Patients with sleep apnea may be managed with continuous positive pressure (CPAP) or bilevel positive airway pressure (BiPAP) devices, both before and after operations. The presence of sleep apnea may also influence anesthesia techniques.

Patients identified as being at highest risk for the development of PPC may benefit from preoperative consultations with respiratory therapy and pulmonary medicine experts. Pulmonary function tests and baseline arterial blood gas tests guide the care of select patients, especially those anticipating lung resections. In addition to smoking cessation, asthma should be medically controlled. Patient education focuses upon inspiratory muscle training (including the usage of incentive spirometry), the concepts of postoperative mobilization, deep inspiration, and coughing, along with oral hygiene (tooth brushing and mouth washes). Respiratory therapists can provide expertise with CPAP and BiPAP systems for patients with sleep apnea. Surgeons and anesthesiologists should collaborate regarding plans for neuromuscular blocking agents and strategies to reduce pain, including the administration of epidural analgesics and the consideration of minimally invasive techniques to avoid large abdominal or thoracic incisions. Finally, formal intensive care unit protocols can promote liberation from ventilator support.

Venous Thromboembolism