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�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

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.�

�� 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

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�

� � �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].��

� � � � � � �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�

�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�

� � �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�

� � �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��

�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

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

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� � � � � �

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.)�

�� 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�

� � �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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�� 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.�

� � �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-�

� � � � � � �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

�� 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�

� � � � � �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?��

� � � � � �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.� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� 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��

� � � � � � � � � � �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��

�� • 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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