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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

Preop Medical Evaluation of the Healthy Patient

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Page 1: Preop Medical Evaluation of the Healthy Patient

�Preoperative medical evaluation of the healthy patient� � � � � � � � � � � � � � � � � � � ����� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Official reprint from� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �www.upt� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �©2010 U���� � �Preoperative medical evaluation of the healthy patient�� � �Author� � � � � � � � � � � � � � � � � � � � � � � �Section Editor� � � � � � � � � � � � � �Gerald W Smetana, MD� � � � � � � � � �Mark D Aronson, MD� � � � � � � � � � �Pracha Eamr� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � ��� � �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. 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 my�� � �institutions, guidelines still require routine laboratory testing despite compelling evidence�� � �showing no benefit of such testing. A systematic review of three randomized trial

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s 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 perce 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.������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 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.�

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�� � �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].������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

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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 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�

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� � �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�����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 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].��

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� � � � � � �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 — Several review articles in perioperative consultation and���� � �most local institutional policies support a selective approach to preoperative testing�� � �[3,6,16,29-32]. A practice advisory from the American Society of Anesthesiologists�� � �recommends against routine preoperative laboratory testing in the absence of clinical�� � �indications [29].��� � �Timing of laboratory testing — When laboratory tests are felt to be necessary, it is���� � �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 usefulness of������http://www.uptodate.com/online/content/topic.do?topicKey=med_cons/6474&view=print� � � � � � 1/22/2010�

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�Preoperative medical evaluation of the healthy patient� � � � � � � � � � � � � � � � � � � ���� � �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.��� � �Laboratory studies — While preoperative laboratory testing is not routinely indicated,���� � �selective testing is appropriate in specific circumstances, including patients with known�� � �underlying diseases or risk factors that would affect operative management or increase risk,�� � �and specific high risk surgical procedures. Specific laboratory studies commonly ordered for�� � �preoperative evaluation include a complete blood count, electrolytes, renal function, blood�� � �glucose, liver function studies, hemostasis evaluation, and urinalysis [31]. These tests are�� � �discussed below with indications for their use in specific populations and surgeries.��� � � � � �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 study of older�� � �veterans (n = 310,311, age ≥65 years) found an increase in 30-day postoperative mortality���� � �for patients with mildly abnormal preoperative hematocrits undergoing major noncardiac�� � �surgery, even in the absence of significant blood loss [33]. Adjusted mortality increased by�� � �1.6 percent (95% CI 1.1 to 2.2 percent) for every one percentage point increase or�� � �decrease from a normal hematocrit, defined as 39.0 to 53.9 percent. The data cannot�� � �distinguish whether an abnormal hematocrit serves as a marker for coexistent disease that�� � �increases mortality risk, or whether the anemia itself increases physiologic stresses and�

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� � �therefore complication rates. Thus, it is unclear if the increased risk is modifiable by�� � �interventions aimed at correcting the hematocrit.��� � �A baseline hemoglobin measurement is suggested for all patients 65 years of age or older�� � �who are undergoing major surgery, and for younger patients undergoing major surgery that�� � �is expected to result in significant blood loss. In contrast, hemoglobin measurement is not�� � �necessary for those undergoing minor surgery unless the history suggests anemia.��� � �The frequency of significant unsuspected white blood cell or platelet abnormalities is low�� � �[3]. Unlike the hemoglobin concentration, however, there is little rationale to support�� � �baseline testing of either. Nevertheless, obtaining a complete blood count, including white�� � �count and platelet measurement, can be recommended if the cost is not substantially�� � �greater than the cost of a hemoglobin concentration alone. There may be some costs�� � �incurred due to follow-up of false positive results; however, with respect to platelet 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 complications�� � �[11] and a major predictor of postoperative mortality [37]. Renal insufficiency necessitates�� � �dosage adjustment of some medications that may be used perioperatively (eg, muscle�� � �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 is no clear�

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� � �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 predict most�� � �abnormalities based on history (for example, current use of a diuretic, angiotensin�� � �converting enzyme (ACE) inhibitor, or angiotensin receptor blocker (ARB), or known chronic�� � �renal insufficiency).��� � �Thus, routine electrolyte determinations are NOT recommended unless the patient has a�� � �history that increases the likelihood of an abnormality.��� � � � � �Blood glucose — The frequency of glucose abnormalities increases with age; almost 25 ���� � �percent of patients over age 60 had an abnormal value in one report [35]. Most controlled�� � �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]. There is no�� � �evidence that asymptomatic hyperglycemia, in a patient not previously known to have�� � �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 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.��� � � � � �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 analysis, 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�����

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�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 most likely be�� � �suspected on the basis of the history and physical examination; thus, routine liver 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 have a low risk�� � �of hemorrhage on the basis of history and physical examination [41,42]. In a pooled data�� � �analysis, an abnormal PT had a positive likelihood ratio of 0 for predicting a postoperative�� � �complication, and a negative likelihood ratio of 1.01 (table 3); in no case did the finding of�� � �an abnormal PT change patient management or modify the likelihood of a complication [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 testing in�� � �patients with a known bleeding diathesis or an illness associated with bleeding tendency�� � �(table 6). The role of preoperative hemostasis evaluation in patients undergoing�� � �intermediate to high risk surgical procedures is somewhat controversial. We suggest NOT�� � �performing PT and PTT in such patients. Others, including authors for UpToDate, have�� � �suggested testing all patients undergoing intermediate to high risk surgical procedures, 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 "Preoperative�� � �assessment of hemostasis".)��� � � � � �Urinalysis — The theoretical reason to obtain a preoperative urinalysis is detection of ���� � �unsuspected renal disease and/or urinary tract infection. Asymptomatic renal disease 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

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nalysis and�� � �urine culture are generally treated with antibiotics and proceed with surgery without delay�� � �[46]. However, it is unclear whether a positive preoperative urinalysis and culture with�� � �subsequent antibiotic treatment prevent post-surgical infection. One study found no�� � �difference in wound infection between patients with normal and abnormal urinalysis [47].�� � �Another study found that patients with asymptomatic urinary tract infection detected by�� � �urinalysis had an increased risk of wound infection post-operatively, despite treatment [48].��� � �A cost-effectiveness analysis estimated that 4.58 wound infections in nonprosthetic 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 procedures.��� � �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".)�����http://www.uptodate.com/online/content/topic.do?topicKey=med_cons/6474&view=print� � � � � � 1/22/2010��Preoperative medical evaluation of the healthy patient� � � � � � � � � � � � � � � � � � � ����� � �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 sur

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gery.�� � �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.��� � �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������http://www.uptodate.com/online/content/topic.do?topicKey=med_cons/6474&view=print� � � � � �

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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 percent) 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 abnormalities on�� � �preoperative chest x-ray.��� � �While routine preoperative chest x-rays are not indicated, we agree with the American�� � �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 Association�� � �for patients with severe obesity (BMI ≥40 kg/m2) [53]. In these patients, the chest���� � �radiograph may indicate undiagnosed heart failure, cardiac chamber enlargement, or�� � �abnormal pulmonary vascularity suggestive of pulmonary hypertension, warranting further�� � �cardiovascular investigation. The relationship between findings on chest x-ray and�� � �perioperative morbidity are not well defined in these populations, however, and studies are�� � �not available that indicate that preoperative radiography changes perioperative outcomes.�� � �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 remains�� � �unexplained after careful clinical evaluation. Clinical findings are more predictive of the risk�� � �of postoperative pulmonary complication than are spirometric results [60]. These findings�� � �include decreased breath sounds, prolonged expiratory phase, rales, rhonchi, or wheezes.��� � �SUMMARY AND RECOMMENDATIONS — The overall risk of surgery is low in healthy���� � �individuals. Preoperative tests usually lead to false positive results, unnecessary costs, and�� � �a potential delay of surgery. Preoperative tests should not be performed unless there is a�� � �clear clinical indication.��� � � � � � �A simple screening questionnaire can be helpful in the preoperative evaluation (table 4).�� � �Important potential risk factors to discuss with the patient include age, exercise capacity,�� � �and medication use. Obesity is not a risk factor for most major adverse postoperative�� � �outcomes in patients undergoing noncardiac surgery. (See 'Clinical evaluation' above.)�

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�� � � � � � �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 results and/or�� � �increased medicolegal risk for not following up on abnormal test results (see 'Rationale for�� � �selective testing' above).��� � � � � �We suggest baseline hemoglobin measurement for all patients 65 years of age or older�� � �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 patients, we�� � �suggest NOT performing routine hemoglobin, white blood count, or platelet measurements�� � �(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 likel� � �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 'Laboratory�� � �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 suggest�� � �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 evaluation in�� � �patients with preexisting cardiovascular disease who are undergoing surgery. This is�� � �discussed in detail elsewhere. (See "Estimation of cardiac risk prior to noncardiac surgery",�� � �section on 'Resting electrocardiogram' and 'Electrocardiogram' above.)��� � � � � � �We suggest that clinicians NOT order routine preoperative chest x-rays or pulmonary�� � �function tests in the healthy patient (Grade 2B). We suggest obtaining a preoperative�

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� � �chest x-ray 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 (Grade 2C). (See 'Chest radiograph' above and 'Pulmonary function tests' above.)���� � � � � � � � � � � � � �Use of UpToDate is subject to the Subscription and License Agreemen��� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �REFEREN�� � � �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������http://www.uptodate.com/online/content/topic.do?topicKey=med_cons/6474&view=print� � � � � � 1/22/2010��Preoperative medical evaluation of the healthy patient� � � � � � � � � � � � � � � � � � � ���� � � � � � � �elderly. Ann Surg 1982; 195:90.�� � �10. Finlayson, EV, Birkmeyer, JD. Operative mortality with elective surgery in older adults.�� � � � � � �Eff Clin Pract 2001; 4:172.�� � �11. Smetana, GW, Lawrence, VA, Cornell, JE. Preoperative pulmonary risk stratification for�� � � � � � �noncardiothoracic surgery: systematic review for the American College of Physicians.�� � � � � � �Ann Intern Med 2006; 144:581.�� � �12. Hosking, MP, Warner, MA, Lobdell, CM, et al. Outcomes of surgery in patients 90 years�� � � � � � �of age and older. JAMA 1989; 261:1909.�� � �13. Polanczyk, CA, Marcantonio, E, Goldman, L, et al. Impact of age on perioperative�

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� � � � � � �complications and length of stay in patients undergoing noncardiac surgery. Ann�� � � � � � �Intern Med 2001; 134:637.�� � �14. Warner, MA, Saletel, RA, Schroeder, DR, et al. Outcomes of anesthesia and surgery in�� � � � � � �people 100 years of age and older. J Am Geriatr Soc 1998; 46:988.�� � �15. Lubin, MF. Is age a risk factor for surgery? Med Clin North Am 1993; 77:327.�� � �16. Fleisher, LA, Beckman, JA, Brown, KA, et al. 2009 ACCF/AHA focused update on�� � � � � � �perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on�� � � � � � �perioperative cardiovascular evaluation and care for noncardiac surgery: a report of�� � � � � � �the American College of Cardiology Foundation/American Heart Association Task Force�� � � � � � �on Practice Guidelines. Circulation 2009; 120:e169.�� � �17. Hlatky, MA, Boineau, RE, Higginbotham, MB, et al. A brief self-administered�� � � � � � �questionnaire to determine functional capacity (the Duke Activity Status Index). Am J�� � � � � � �Cardiol 1989; 64:651.�� � �18. Reilly, DF, McNeely, MJ, Doerner, D, et al. Self-reported exercise tolerance and the�� � � � � � �risk of serious perioperative complications. Arch Intern Med 1999; 159:2185.�� � �19. Yap, CH, Zimmet, A, Mohajeri, M, Yii, M. Effect of obesity on early morbidity and�� � � � � � �mortality following cardiac surgery. Heart Lung Circ 2007; 16:31.�� � �20. Kuduvalli, M, Grayson, AD, Oo, AY, et al. Risk of morbidity and in-hospital mortality in�� � � � � � �obese patients undergoing coronary artery bypass surgery. Eur J Cardiothorac Surg� � � � � � �2002; 22:787.�� � �21. Zacharias, A, Schwann, TA, Riordan, CJ, et al. Obesity and risk of new-onset atrial�� � � � � � �fibrillation after cardiac surgery. Circulation 2005; 112:3247.�� � �22. Klasen, J, Junger, A, Hartmann, B, et al. Increased body mass index and peri-�� � � � � � �operative risk in patients undergoing non-cardiac surgery. Obes Surg 2004; 14:275.�� � �23. Mullen, JT, Moorman, DW, Davenport, DL. The obesity paradox: body mass index and�� � � � � � �outcomes in patients undergoing nonbariatric general surgery. Ann Surg 2009;�� � � � � � �250:166.�� � �24. Dindo, D, Muller, MK, Weber, M, Clavien, PA. Obesity in general elective surgery.�� � � � � � �Lancet 2003; 361:2032.�� � �25. Thomas, EJ, Goldman, L, Mangione, CM, et al. Body mass index as a correlate of�� � � � � � �postoperative complications and resource utilization. Am J Med 1997; 102:277.�� � �26. Herrera, FA, Yanagawa, J, Johnson, A, et al. The prevalence of obesity and�� � � � � � �postoperative complications in a Veterans Affairs Medical Center general surgery�� � � � � � �population. Am Surg 2007; 73:1009.�� � �27. Hofer, RE, Kai, T, Decker, PA, Warner, DO. Obesity as a risk factor for unanticipated�� � � � � � �admissions after ambulatory surgery. Mayo Clin Proc 2008; 83:908.�� � �28. Smetana, GW. Preoperative pulmonary evaluation. N Engl J Med 1999; 340:937.�� � �29. Practice advisory for preanesthesia evaluation: a report by the American Society of�� � � � � � �Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 2002;�����http://www.uptodate.com/online/content/topic.do?topicKey=med_cons/6474&view=print� � � � � � 1/22/2010��Preoperative medical evaluation of the healthy patient� � � � � � � � � � � � � � � � � � � ��

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�� � � � � � � �96:485.�� � �30. Macpherson, DS, Snow, R, Lofgren, RP. preoperative screening: value of previous�� � � � � � �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 assessment.�� � � � � � �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 2007;�� � � � � � �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 Predicting�� � � � � � �Postoperative Complications: A Multivariate Analysis. Surgery 1991; 109:236.�� � �36. Lee, TH, Marcantonio, ER, Mangione, CM, et al. Derivation and prospective validation�� � � � � � �of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation�� � � � � � �1999; 100:1043.�� � �37. Mathew, A, Devereaux, PJ, O'Hare, A, et al. Chronic kidney disease and postoperative�� � � � � � �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 Intern� � � � � � �Med 1989; 110:859.�� � �39. Higgins, T, Estafanous, F, Loop, F, et al. Stratification of morbidity and mortality�� � � � � � �outcome of preoperative risk factors in coronary artery bypass patients. JAMA 1992;�� � � � � � �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 perioperative�� � � � � � �hemostasis. Can J Anaesth 2006; 53:S12.�� � �43. Rodgers, RP, Levin, J. A critical reappraisal of the bleeding time. Semin Thromb�� � � � � � �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 Clinical�� � � � � � �Pathologists' position article. Arch Surg 1998; 133:134.�� � �45. Koulouvaris, P, Sculco, P, Finerty, E, et al. Relationship between perioperative urinary�� � � � � � �tract infection and deep infection after joint arthroplasty. Clin Orthop Relat Res 2009;�� � � � � � �467:1859.�

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� � �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. Arch Intern�� � � � � � �Med 1988; 148:1370.�� � �48. Ollivere, BJ, Ellahee, N, Logan, K, et al. Asymptomatic urinary tract colonisation�� � � � � � �predisposes to superficial wound infection in elective orthopaedic surgery. Int Orthop�� � � � � � �2009; 33:847.�� � �49. Lawrence, VA, Kroenke, K. The unproven utility of the preoperative urinalysis:�� � � � � � �Economic evaluation. J Clin Epidemiol 1989; 42:1185.�����http://www.uptodate.com/online/content/topic.do?topicKey=med_cons/6474&view=print� � � � � � 1/22/2010��Preoperative medical evaluation of the healthy patient� � � � � � � � � � � � � � � � � � � ���� � �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 meta-�

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� � � � � � �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 complications after�� � � � � � �abdominal surgery. Chest 1996; 110:744.������http://www.uptodate.com/online/content/topic.do?topicKey=med_cons/6474&view=print� � � � � � 1/22/2010��Preoperative medical evaluation of the healthy patient� � � � � � � � � � � � � � � � � � � ������ � �GRAPHICS������http://www.uptodate.com/online/content/topic.do?topicKey=med_cons/6474&view=print� � � � � �11/22/2010��Preoperative medical evaluation of the healthy patient� � � � � � � � � � � � � � � � � � � ����� � � � � �Probability of an abnormal screening test result��� � � � � � � � � � � � � � �Number of independent tests� � � � � � � � � � � � � � � � �Proba� � � � � � � � � � �1� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� � � � � � � � � � �2� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� � � � � � � � � � �4� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� � � � � � � � � � �6� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� � � � � � � � � � �10� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � ��� � � � � � � � � � �20� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � ��� � � � � � � � � � �50� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � ������http://www.uptodate.com/online/content/topic.do?topicKey=med_cons/6474&view=print� � � � � � 1/22/2010��Preoperative medical evaluation of the healthy patient� � � � � � � � � � � � � � � � � � � ����� � � � � �Predictive value of positive test results��� � � � � � � � � � � � � � � � �Prevalence of disease,� � � � � � � � � � � �Predictive value� � � � � � � � � � � � � � � � � � � � � � � �percent� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �0.1� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �1

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�� � � � � � � � � � �1.0� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �1�� � � � � � � � � � �2.0� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �2�� � � � � � � � � � �5.0� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �5�� � � � � � � � � � �50.0� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �95�����http://www.uptodate.com/online/content/topic.do?topicKey=med_cons/6474&view=print� � � � � � 1/22/2010��Preoperative medical evaluation of the healthy patient� � � � � � � � � � � � � � � � � � � ����� � � � � �Value of preoperative tests in influencing preoperative�� � � � � �management and predicting postoperative complications��� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Incidence of� � � � � � � � �� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �abnormalities� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �that influence� � � � � � � �po� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �management,� � � � � � � � � � � � � � � � � � � � � � � � � � �Test� � � � � � � � � � � � � � �percent� � � � � � � � � � �� � � � � � � � � � �Hemoglobin� � � � � � � � � � �0.1� � � � � � � � � � � � � � � � � � �3.�� � � � � � � � � � �White blood cell� � � � �0.0� � � � � � � � � � � � � � � � � � �0.0� � �� � � � � � � � � � �count��� � � � � � � � � � �Platelet count� � � � � � �0.0� � � � � � � � � � � � � � � � � � �0.0� ��� � � � � � � � � � �Prothrombin time� � � � �0.0� � � � � � � � � � � � � � � � � � �0.0� � �� � � � � � � � � � �(PT)��� � � � � � � � � � �Partial� � � � � � � � � � � � � �0.1� � � � � � � � � � � � � � � � � � � � � � � � � � � � �thromboplastin�� � � � � � � � � � �time (PTT)��� � � � � � � � � � �Electrolytes� � � � � � � � �1.8� � � � � � � � � � � � � � � � � � �4.3*�� � � � � � � � � � �Renal function� � � � � � �2.6� � � � � � � � � � � � � � � � � � �3.3� ��� � � � � � � � � � �Glucose� � � � � � � � � � � � � �0.5� � � � � � � � � � � � � � � � � � �� � � � � � � � � � �Liver function� � � � � � �0.1� � � � � � � � � � � � � � � � � � �NA**� � � � � � � � � � � �tests��� � � � � � � � � � �Urinalysis� � � � � � � � � � �1.4� � � � � � � � � � � � � � � � � � �1.�� � � � � � � � � � �Electrocardiogram� � � �2.6� � � � � � � � � � � � � � � � � � �1.6� � � �� � � � � � � � � � �Chest radiograph� � � � �3.0� � � � � � � � � � � � � � � � � � �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�

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� � � � � �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. �������http://www.uptodate.com/online/content/topic.do?topicKey=med_cons/6474&view=print� � � � � � 1/22/2010��Preoperative medical evaluation of the healthy patient� � � � � � � � � � � � � � � � � � � ����� � � � � �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 an� � � � � � � � � � �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 anaesthe� � � � � � � � � � �problems?��� � � � � � � � � � �8. Do you suffer from epilepsy or seizures?��� � � � � � � � � � �9. Do you have any problems with pain, stiffness or arthritis in your nec?��� � � � � � � � � � �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?��

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� � � � � �Data from: Hilditch, WG, Asbury, AJ, Jack, E, McGrane, S. Validation of a pre-anaesthetic�� � � � � �screening questionnaire. Anaesthesia 2003; 58:874.������http://www.uptodate.com/online/content/topic.do?topicKey=med_cons/6474&view=print� � � � � � 1/22/2010��Preoperative medical evaluation of the healthy patient� � � � � � � � � � � � � � � � � � � ����� � � � � �ASA physical status classification system��� � � � � � � � � � �ASA� � � � � � � � � � �Physical� � � � � � � � � � � �Functional�� � � � � � � � � � �class� � � � � � � � � �status� � � � � � � � � � � � � � �status� � � � � � � � � � � � � � �1� � � � � � � � � �Healthy, no� � � � � � � � �Can walk up one� � � � � � � � � � � � � � � � � � � � � � � � � �disease outside� � � � �flight of stairs or� � � � � � � � � � � � � � � � � � � � � � � � � �surgical process� � � �two level city�� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �blocks without�� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �distress�� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �Little or no an�� � � � � � � � � � �2� � � � � � � � � �Mild to moderate� � � �Can walk up one� � � � � � � �� � � � � � � � � � � � � � � � � � � � �systemic� � � � � � � � � � � �flight of stairs or� �� � � � � � � � � � � � � � � � � � � � �disease,� � � � � � � � � � � �two level city� � � � � � � � � � � � � � � � � � � � � � � � �medically well� � � � � �blocks but will� � � � � � �� � � � � � � � � � � � � � � � � � � � �controlled, with� � � �have to stop after� � � � � �o� � � � � � � � � � � � � � � � � � � � �no functional� � � � � � �completion of the� � � � � � � � � � � � � � � � � � � � � � � � � �limitation� � � � � � � � � �exercise because� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �of distress�� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �ASA I with extr� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �anxiety and fea� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �respiratory�� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �condition,�� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �pregnancy or�� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �active allergie�� � � � � � � � � � �3� � � � � � � � � �Severe systemic� � � � �Can walk up one� � � � � � � � � � � � � � � � � � � � � � � � � � � �disease that� � � � � � � �flight of stairs or� � � �� � � � � � � � � � � � � � � � � � � � �results in� � � � � � � � � �two level city� � � � � � � � � � � � � � � � � � � � � � � � � �functional� � � � � � � � � �blocks but will� � � � �� � � � � � � � � � � � � � � � � � � � �limitation� � � � � � � � � �have to stop� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �enroute because� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �distress� � � �� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� � � � � � � � � � �4� � � � � � � � � �Severe� � � � � � � � � � � � � �Unable to walk up� �� � � � � � � � � � � � � � � � � � � � �incapacitating� � � � � �one flight of stairs� � � �a� � � � � � � � � � � � � � � � � � � � �disease process� � � � �or two level city� � � � � � � � � � � � � � � � � � � � � � � � � � �that is a� � � � � � � � � � �blocks. Distress is� � � � � � � � � � � � � � � � � � � � � � �constant threat� � � � �present even at� � � � � � � � � � � � � � � � � � � � � � � � � � � �to life� � � � � � � � � � � � �rest.� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �

Page 23: Preop Medical Evaluation of the Healthy Patient

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� � � � � � � � � � �5� � � � � � � � � �Moribund patient� � � � � � � � � � � � � � � � � � �� � � � � � � � � � � � � � � � � � � � �not expected to� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �survive 24 hours� � � � � � � � � � � � � � � � � � �� � � � � � � � � � � � � � � � � � � � �without an� � � � � � � � � � � � � � � � � � � � � �� � � � � � � � � � � � � � � � � � � � �operation� � � � � � � � � � � � � � � � � � � � � � �����http://www.uptodate.com/online/content/topic.do?topicKey=med_cons/6474&view=print� � � � � � 1/22/2010��Preoperative medical evaluation of the healthy patient� � � � � � � � � � � � � � � � � � � ���� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� � � � � � � � � � �6� � � � � � � � � �A declared�� � � � � � � � � � � � � � � � � � � � �brain-dead�� � � � � � � � � � � � � � � � � � � � �patient being�� � � � � � � � � � � � � � � � � � � � �maintained for�� � � � � � � � � � � � � � � � � � � � �harvesting of�� � � � � � � � � � � � � � � � � � � � �organs��� � � � � � � � � � �E� � � � � � � � � �Suffix to indicate� � � �Any patient in� � � �Otherwi� � � � � � � � � � � � � � � � � � � � �emergency� � � � � � � � � � � � �whom an� � � � � � � � � � � � � � � � � � � � � � � � � � �surgery for any� � � � � � �emergency� � � � � � � � � � � � � � � � � � � � � � � � � � � � �class� � � � � � � � � � � � � � � � �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 System:�� � � � � �http://www.dhed.net/ASA%20Physical%20Status%20Classification%20SYSTEM.htm.������http://www.uptodate.com/online/content/topic.do?topicKey=med_cons/6474&view=print� � � � � � 1/22/2010��Preoperative medical evaluation of the healthy patient� � � � � � � � � � � � � � � � � � � ����� � � � � �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����

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� � � � � � � � � � �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 Fleisher, LA,�� � � � � �Beckman, JA, Brown, KA, et al. 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 2002 Guidelines on Perioperative Cardiovascular�� � � � � �Evaluation for Noncardiac Surgery) developed in collaboration with the American Society�� � � � � �of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society,�� � � � � �Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and�� � � � � �Interventions, Society for Vascular Medicine and Biology, and Society for Vascular�� � � � � �Surgery. J Am Coll Cardiol 2007; 50:e159.������http://www.uptodate.com/online/content/topic.do?topicKey=med_cons/6474&view=print� � � � � � 1/22/2010��Preoperative medical evaluation of the healthy patient� � � � � � � � � � � � � � � � � � � ����� � � � � �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 suredures���

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�� � � � � � � � � � �• Patients with atherosclerotic cardiovascular disease scheduled for inteisk���� � � � � � � � � � �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 pr�� � � � � � � � � � �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 in-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 proced�� � � � � �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, Ornato JP,�� � � � � �Page RL, Riegel B, Tarkington LG, Yancy CW; American College of Cardiology; American�� � � � � �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; Heart�� � � � � �Rhythm Society; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular�� � � � � �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 2002�� � � � � �Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed�� � � � � �in collaboration with the American Society of Echocardiography, American Society of�� � � � � �Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists,�� � � � � �Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine�� � � � � �and Biology, and Society for Vascular Surgery.�� � � � � �J Am Coll Cardiol. 2007 Oct 23;50(17):e159-241.����� � �© 2010 UpToDate, Inc. All rights reserved. | Subscription and License Agreement�� � � �|� rt Tag:�� � �[ecapp1103p.utd.com-192.240.41.144-67A40DFD2C-1017]�

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