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Preoperativemedicalevaluationofthehealthypatient

Preoperativemedicalevaluationofthehealthypatient

Author SectionEditor DeputyEditor


GeraldWSmetana, MarkDAronson,MD PrachaEamranond,
MD MD,MPH

Disclosures

Lastliteraturereviewversion19.3:FriSep3000:00:00
GMT2011 | Thistopiclastupdated:MonJun2700:00:00
19.3
GMT2011 (More)
INTRODUCTIONCliniciansareoftenaskedtoevaluatea
patientpriortosurgery.Themedicalconsultantmaybeseeing
Preoperativemedicalevaluationofthehealthypatient Find Patient Print

thepatientattherequestofthesurgeon,ormaybetheprimary
TOPICOUTLINE careclinicianassessingthepatientpriortoconsiderationofa
surgicalreferral.Thegoaloftheevaluationofthehealthy
INTRODUCTION
patientistodetectunrecognizeddiseaseandriskfactorsthat
RATIONALEFORSELECTIVE mayincreasetheriskofsurgeryabovebaselineandtopropose
TESTING strategiestoreducethisrisk.
Predictivevalue
Theevaluationofhealthypatientspriortosurgeryisreviewed
CLINICALEVALUATION
here.Preoperativeassessmentsforspecificsystemsissuesand
Screeningquestionnaire
surgicalproceduresarediscussedseparately.(See"Estimationof
Age
cardiacriskpriortononcardiacsurgery"and"Perioperative
Exercisecapacity medicationmanagement"and"Overviewoftheprinciplesof
Medicationuse medicalconsultationandperioperativemedicine"and"Evaluation
Obesity ofpreoperativepulmonaryrisk".)
Alcoholmisuse
Smoking RATIONALEFORSELECTIVETESTINGTheprevalenceof
unrecognizeddiseasethatinfluencessurgicalriskislowin
LABORATORYEVALUATION
healthyindividuals.Nevertheless,cliniciansoftenperform
Timingoflaboratorytesting
laboratorytestsinthisgroupofpatientsoutofhabitand
Laboratorystudies medicolegalconcern,withlittlebenefitandahighincidenceof
Completebloodcount falsepositiveresults.Representativestudiesthathaveaddressed
Renalfunction thisissueinclude:
Electrolytes
Bloodglucose Inatrialof1061ambulatorysurgicalpatientsrandomly
Liverfunctiontests assignedtopreoperativetestingornotesting,therewas
Testsofhemostasis nodifferenceinperioperativeadverseeventsorevents
Urinalysis within30daysofambulatorysurgery[1].Patients
Pregnancytesting assignedtotestingcouldreceiveacompletebloodcount,
electrolytes,bloodglucose,creatinine,electrocardiogram,
ELECTROCARDIOGRAM
and/orchestradiograph,basedontheOntarioPreoperative
CHESTRADIOGRAPH
TestingGrid.
PULMONARYFUNCTIONTESTS
Medicalconsultantscommonlyseepatientsbeforeplanned
INFORMATIONFORPATIENTS
cataractsurgery.Inmanyinstitutions,guidelinesstill
SUMMARYAND
requireroutinelaboratorytestingdespitecompelling
RECOMMENDATIONS
evidenceshowingnobenefitofsuchtesting.Asystematic
REFERENCES
REFERENCES reviewofthreerandomizedtrialsoftestingversusno
GRAPHICSViewAll testinginatotalof21,531cataractsurgeriesfoundthat
adverseeventsdidnotdifferbetweenthetwogroups[2].
TABLES
Institutionsmaysafelyeliminatearequirementforroutine
Probabilityabnormaltest laboratorytestsbeforecataractsurgery.
Predictivevaluepositivetests
Likelihoodratiospreoptests Inaretrospectivestudyof2000patientsundergoing
Preopevaluationquestions electivesurgery,60percentofroutinelyorderedtests
ASAclassification(expanded wouldnothavebeenperformediftestinghadonlybeen
version) doneforrecognizableindicationsonly0.22percentof
AUDITC theserevealedabnormalitiesthatmightinfluence
ACCAHApreoperativeECG perioperativemanagement[3].Furtherchartreview
determinedthattheseabnormalitieswerenotactedupon,
RELATEDTOPICS nordidtheyhaveadversesurgicalconsequences.
HelpimproveUpToDate.DidUpToDateansweryourquestion? Yes No
Diagnosisandclinical
Onereportfoundthatonlytenroutinelaboratorytest
resultsin3782patientsrequiredtreatmentjustoneof
19.3
theserequiredpharmacologictreatment[4].Inasecond
reviewof5003preoperativescreeningtestsin2570
patients,only104testswereabnormalandpotentially
Preoperativemedicalevaluationofthehealthypatient Find

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Print
significant[5].Screeningmodifiedpreoperative
managementinonlyfourpatients.
TOPICOUTLINE

INTRODUCTION PredictivevalueThereareseveralargumentsforavoiding
RATIONALEFORSELECTIVE routinepreoperativetests.Normaltestvaluesareusually
TESTING arbitrarilydefinedasthoseoccurringwithintwostandard
Predictivevalue deviationsfromthemean,therebyensuringthat5percentof
CLINICALEVALUATION healthyindividualswhohaveasinglescreeningtestwillhavean
abnormalresult.Asmoretestsareordered,thelikelihoodofa
Screeningquestionnaire
falsepositivetestincreasesascreeningpanelcontaining20
Age
independenttestsinapatientwithnodiseasewillyieldatleast
Exercisecapacity
oneabnormalresult64percentofthetime(table1).
Medicationuse
Obesity Thus,thepredictivevalueofabnormaltestresultsislowin
Alcoholmisuse healthypatientswithalowprevalenceofdisease(table2).Aside
Smoking frompossiblycausingpatientalarm,theadditionaltesting
promptedbyfalsepositivescreeningtestsleadstounnecessary
LABORATORYEVALUATION
costs,risks,andapotentialdelayofsurgery.Inaddition,
Timingoflaboratorytesting
cliniciansoftenfailtoactuponabnormaltestresultsfrom
Laboratorystudies
routinepreoperativetesting,therebycreatinganadditional
Completebloodcount
medicolegalrisk.
Renalfunction
Electrolytes Areviewofstudiesofroutinepreoperativetestingpooleddata
Bloodglucose andestimatedtheincidenceofabnormalitiesthataffectpatient
Liverfunctiontests managementandthepositiveandnegativelikelihoodratiosfora
Testsofhemostasis postoperativecomplication(table3)[6].Fornearlyallpotential
laboratorystudies,anormaltestdidnotsubstantiallyreducethe
Urinalysis
likelihoodofapostoperativecomplication(thenegativelikelihood
Pregnancytesting
ratioapproached1.0).Positivelikelihoodratiosweremodest,
ELECTROCARDIOGRAM
andtheyexceeded3.0foronlythreetests(hemoglobin,renal
CHESTRADIOGRAPH function,andelectrolytes)however,clinicalevaluationcan
PULMONARYFUNCTIONTESTS predictmostpatientswithanabnormalresult.Thiswas
INFORMATIONFORPATIENTS illustratedbythelowincidenceofachangeinpreoperative
managementbasedonanabnormaltestresult(zeroto3
SUMMARYAND
percent).
RECOMMENDATIONS
REFERENCES
REFERENCES

GRAPHICSViewAll

TABLES
Probabilityabnormaltest
Predictivevaluepositivetests
Likelihoodratiospreoptests CLINICALEVALUATIONIngeneral,theoverallriskof
Preopevaluationquestions surgeryisextremelylowinhealthyindividuals.Therefore,the
ASAclassification(expanded abilitytostratifyriskbycommonlyperformedevaluationsis
version) limited.
AUDITC
ScreeningquestionnaireScreeningquestionsappearon
ACCAHApreoperativeECG
manystandardinstitutionalpreoperativeevaluationforms.One
RELATEDTOPICS validatedscreeninginstrument,derivedfrom100patients,
HelpimproveUpToDate.DidUpToDateansweryourquestion?
comprises17questionsthatallowednursestoidentifythose Yes No
Diagnosisandclinical
patientswhowouldbenefitfromaformalpreoperative
19.3 evaluationbyananesthesiologist[7](table4).Thequestions
chosenforthisquestionnaireweredevisedtodetectpreexisting
conditionsshowntobeassociatedwithperioperativeadverse
events.
Preoperativemedicalevaluationofthehealthypatient Find Patient Print

AgeAnumberofcommonlyemployedandvalidatedindices
TOPICOUTLINE
considerageasaminorcomponentofpreoperativecoronary
INTRODUCTION risk.(See"Estimationofcardiacriskpriortononcardiac
RATIONALEFORSELECTIVE surgery".)
TESTING
Somestudiesfoundasmallincreasedriskofsurgeryassociated
Predictivevalue withadvancingage[8,9].Inareviewof50,000elderlypatients,
CLINICALEVALUATION forexample,theriskofmortalitywithelectivesurgeryincreased
Screeningquestionnaire from1.3percentforthoseunder60yearsofage,to11.3
Age percentinthe80to89yearoldagegroup[9].Among1.2
Exercisecapacity millionMedicarepatientsundergoingelectivesurgery,mortality
Medicationuse riskincreasedlinearlywithageformostsurgicalprocedures
Obesity [10].Operativemortalityforpatients80yearsandolderwas
Alcoholmisuse morethantwicethatofpatients65to69yearsold.
Smoking Inadditiontotheminorinfluenceofageonperioperativecardiac
LABORATORYEVALUATION risk,thereismorerobustliteraturesupportingageasan
Timingoflaboratorytesting independentriskfactorforpostoperativepulmonary
Laboratorystudies complications.Agewasoneofthemostimportantpatientrelated
Completebloodcount predictorsofpulmonaryrisk,evenafteradjustingforcommon
Renalfunction agerelatedcomorbidities,inasystematicreview[11].(See
Electrolytes "Evaluationofpreoperativepulmonaryrisk".)
Bloodglucose Incontrast,somestudieshavefoundlittlerelationbetweenage
Liverfunctiontests andmortalityratesduetosurgery.Onestudyreportedthe
Testsofhemostasis outcomesofsurgeryin795patientsover90yearsofage[12].
Urinalysis NopatientswereClassIasclassifiedbytheAmericanSocietyof
Pregnancytesting Anesthesiologists(ASA)classification(table5)80percentwere
ELECTROCARDIOGRAM ASAClassIIIorgreater.Despitehigherperioperativemortality
CHESTRADIOGRAPH ratesintheelderly,survivalattwoyearswasnodifferentthan
theactuarialsurvivalinmatchedpatientsnotundergoing
PULMONARYFUNCTIONTESTS
surgery[12].Alargerstudyof4315patientsalsofounda
INFORMATIONFORPATIENTS higherperioperativecomplicationandmortalityrateinolder
SUMMARYAND individuals,butthemortalityratewaslow[13].Among31
RECOMMENDATIONS patientsage100yearsandolderundergoingsurgeryrequiring
REFERENCES
REFERENCES anesthesia,perioperativeandoneyearmortalityrateswere
GRAPHICSViewAll similartomatchedpeersfromthegeneralpopulation[14].

TABLES Muchoftheriskassociatedwithageisduetoincreasing
Probabilityabnormaltest numbersofcomorbiditiesthatconferexcessrisk.Afteradjusting
Predictivevaluepositivetests forcomorbiditiesmorecommonwithage,theimpactofageon
Likelihoodratiospreoptests perioperativeoutcomesismodest.Thus,ageshouldnotbeused
Preopevaluationquestions asthesolecriteriontoguidepreoperativetestingortowithhold
asurgicalprocedure[15].
ASAclassification(expanded
version) ExercisecapacityAllpatientsshouldbeaskedabouttheir
AUDITC exercisecapacityaspartofthepreoperativeevaluation.Exercise
ACCAHApreoperativeECG capacityisanimportantdeterminantofoverallperioperative
riskpatientswithvirtuallyunlimitedexercisetolerance
RELATEDTOPICS
generallyhavelowrisk.
HelpimproveUpToDate.DidUpToDateansweryourquestion? Yes No
Diagnosisandclinical
Theabilitytowalktwoblocksonlevelgroundorcarrytwobags
19.3 ofgroceriesuponeflightofstairswithoutsymptomsaresimple
questionsthatcangivearoughassessmentofpatientrisk[16].
Theseactivitiesexpendapproximately4metabolicenergy
equivalents(METs)[17].(See"Estimationofcardiacriskpriorto
Preoperativemedicalevaluationofthehealthypatient Find Patient Print

noncardiacsurgery",sectionon'Functionalcapacity'.)
TOPICOUTLINE
Ingeneral,healthypatientswhocanperformtheseactivitiesas
INTRODUCTION partoftheirdailyroutinehavealowriskformajorpostoperative
RATIONALEFORSELECTIVE complications.Thiswasillustratedinastudyof600consecutive
TESTING patientsundergoingmajorsurgery[18].Investigatorsasked
Predictivevalue eachpatienttoestimatethenumberofblocksthattheycould
CLINICALEVALUATION walkonlevelgroundandthenumberofflightsofstairsthey
couldclimbwithoutsymptoms.Theauthorsdefinedpoor
Screeningquestionnaire
exercisecapacityastheinabilitytoeitherwalkfourblocksor
Age
climbtwoflightsofstairs.Patientsreportingpoorexercise
Exercisecapacity
capacityhadtwiceasmanyseriouspostoperativecomplications
Medicationuse
asthosewhoreportedgoodexercisecapacity(20versus10
Obesity percent,respectively).Therewasalsoasignificantdifferencein
Alcoholmisuse cardiovascularcomplications(10versus5percent),butnotfor
Smoking totalpulmonarycomplications(9versus6percent).
LABORATORYEVALUATION
Theimportanceoffunctionalcapacitywasconfirmedobjectively
Timingoflaboratorytesting
inanotherreportof847patientsundergoingelectiveabdominal
Laboratorystudies
surgery[19].Inthisstudy,poorexercisecapacity,confirmedby
Completebloodcount
cardiopulmonaryexercisetesting,wasastrongerpredictorofall
Renalfunction causemortalitythananyoftheconventionalcardiacriskfactors
Electrolytes oftheRevisedCardiacRiskIndex.
Bloodglucose
Liverfunctiontests MedicationuseCliniciansshouldobtainahistoryof
Testsofhemostasis medicationuseforallpatientsbeforesurgeryandshould
specificallyinquireaboutoverthecountermedications.Aspirin,
Urinalysis
ibuprofen,andothernonsteroidalantiinflammatorydrugsare
Pregnancytesting
readilyavailableandareassociatedwithanincreasedriskof
ELECTROCARDIOGRAM
perioperativebleeding.Specificinquiryaboutuseof
CHESTRADIOGRAPH complementaryandalternativemedicationsshouldalsobepart
PULMONARYFUNCTIONTESTS ofthepreoperativeassessment.Adetaileddiscussionof
INFORMATIONFORPATIENTS perioperativemedicationmanagementispresentedseparately.
(See"Perioperativemedicationmanagement".)
SUMMARYAND
RECOMMENDATIONS
REFERENCES
REFERENCES

GRAPHICSViewAll

TABLES
Probabilityabnormaltest
Predictivevaluepositivetests
Likelihoodratiospreoptests ObesityContrarytopopularbelief,innoncardiacsurgery,
Preopevaluationquestions obesityisnotariskfactorformostmajoradversepostoperative
ASAclassification(expanded outcomes,withtheexceptionofpulmonaryembolism.Noneof
version) thepublishedandwidelydisseminatedcardiacriskindicesfor
AUDITC noncardiacsurgeryincludeobesityasariskfactorfor
ACCAHApreoperativeECG postoperativecardiaccomplications.

RELATEDTOPICS However,incardiacsurgery,somestudieshaveshownhigher
HelpimproveUpToDate.DidUpToDateansweryourquestion?
complicationratesforobesepatients,includingincreased Yes No
Diagnosisandclinical
hospitalstay[20],woundinfections[20,21],prolonged
19.3 mechanicalventilation[21],andatrialarrhythmias[21,22].

Representativestudiesrelatedtopostoperativemortalityin
noncardiacsurgeryinclude:
Preoperativemedicalevaluationofthehealthypatient Find

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Inamatchedcasecontrolstudyof1962patients
TOPICOUTLINE undergoingnoncardiacsurgery,obesitywasnotassociated
INTRODUCTION withincreasedmortality(1.1percentinobesepatients
RATIONALEFORSELECTIVE versus1.2percentincontrols)[23].
TESTING
Inalarge,multiinstitutional,prospectivecohortof
Predictivevalue 118,707patientsundergoingnonbariatricgeneralsurgery,
CLINICALEVALUATION obesitywasinverselyassociatedwithpostoperative
Screeningquestionnaire mortality(OR0.85,95%CI0.750.99),aphenomenon
Age termedthe'obesityparadox'[24].Theauthorssuggest
Exercisecapacity thattheobesestatecarriesalowgrade,chronic
Medicationuse inflammatorythatmaybe'primed'tomountan
Obesity appropriateinflammatoryandimmuneresponsetothe
Alcoholmisuse stressofsurgery,inadditiontosupplyingmorenutritional
Smoking reserve.
LABORATORYEVALUATION
Otherstudiesrelatingtocomplicationsinnoncardiacsurgery
Timingoflaboratorytesting foundthatobesityincreasesratesforwoundinfections,buthas
Laboratorystudies noeffectonotherpostoperativecomplications[2529].
Completebloodcount
Renalfunction Obesityisalsonotariskfactorforpostoperativepulmonary
Electrolytes conditionsotherthanpulmonaryembolism.Inareviewwhich
foundthattheunadjustedrelativerisksforpulmonary
Bloodglucose
complicationsduetoobesitywere0.8to1.7,theincidenceof
Liverfunctiontests
pulmonarycomplicationswas21percentinbothobeseandnon
Testsofhemostasis
obesepatients[29].Inanothersystematicreview,onlyoneof
Urinalysis
eighteligiblestudiesusingmultivariableanalysistoadjustfor
Pregnancytesting
confoundersfoundthatobesitywasapredictorofpostoperative
ELECTROCARDIOGRAM pulmonaryrisk[11].
CHESTRADIOGRAPH
Theoneexceptiontotheobservationthatobesitydoesnot
PULMONARYFUNCTIONTESTS increasetheriskofnoncardiacsurgeryisvenous
INFORMATIONFORPATIENTS thromboembolism.Obesityisamajorriskfactorfor
SUMMARYAND postoperativedeepvenousthrombosisandpulmonaryembolism.
RECOMMENDATIONS
REFERENCES
REFERENCES (See"Preventionofvenousthromboembolicdiseaseinsurgical
GRAPHICSViewAll patients".)

TABLES
Probabilityabnormaltest
Predictivevaluepositivetests
Likelihoodratiospreoptests AlcoholmisusePatientswhomisusealcoholonaregular
Preopevaluationquestions basishaveanincreasedriskforpostoperativecomplications
ASAclassification(expanded [30].
version)
AUDITC Inastudyof9176maleUSveterans,ascreeningquestionnaire
foralcoholmisuseadministeredatanytimewithinoneyear
ACCAHApreoperativeECG
beforesurgeryaccuratelystratifiedriskofpostoperative
RELATEDTOPICS complications[31].Therewasacontinuousrelationshipbetween
HelpimproveUpToDate.DidUpToDateansweryourquestion?
postoperativecomplicationsandriskscoresusingtheAlcohol Yes No
Diagnosisandclinical
UseDisordersIdentificationTestConsumption(AUDITC)
19.3 questionnaire(table6).Surgicalsiteinfections,otherinfections,
andcardiopulmonarycomplicationseachincreasedacrossthe
strataofriskgroupsbasedonalcoholusepatterns.Asimilarly
conductedtrialoftheAUDITCquestionnairebeforetotaljoint
Preoperativemedicalevaluationofthehealthypatient Find Patient Print

arthroplastyrevealedcomparableresults[32].
TOPICOUTLINE
Mosttrialsofalcoholcessationinterventionshavebeen
INTRODUCTION conductedinthenonoperativesettingasmallstudyinpatients
RATIONALEFORSELECTIVE undergoingcolorectalsurgeryreportedabeneficialeffectof
TESTING alcoholscreeningonpostoperativecomplications[33].The
Predictivevalue optimalperiodofcessationisunknownbutatleastfourweeksof
abstinencearerequiredtoreverseselectedphysiologic
CLINICALEVALUATION
abnormalities[30].
Screeningquestionnaire
Age Screeningforalcoholmisusebeforesurgerywillidentifya
Exercisecapacity subsetofpatientsatincreasedriskforpostoperativemedical
Medicationuse complications.Whilethebenefitofdirectedalcoholcessation
Obesity programsbeforesurgeryisnotwellestablishedintheliterature,
Alcoholmisuse thereislittleapparentrisktosuchastrategy.Pendingfurther
Smoking study,itisreasonabletoscreenallpatientsforalcoholmisuse
beforeelectivemajorsurgery.
LABORATORYEVALUATION
Timingoflaboratorytesting SmokingCurrentsmokingisassociatedwithpostoperative
Laboratorystudies morbidityandmortality[34].Smokingcessationpriortosurgery
Completebloodcount maypreventpostoperativecomplications.
Renalfunction
Ametaanalysisofsixrandomizedtrialsfoundthatstopping
Electrolytes smokingpriortosurgeryledtoalowerriskoftotalpostoperative
Bloodglucose complications(RR0.59,95%CI0.410.85)[35].Thesame
Liverfunctiontests metaanalysisalsopooleddatafrom15observationalstudies
Testsofhemostasis andfoundthatsmokingcessationledtodecreasedwound
Urinalysis healingcomplications(RR0.73,CI0.610.87)andpulmonary
Pregnancytesting complications(RR0.81,CI0.700.93).Longerperiodsof
ELECTROCARDIOGRAM smokingcessationpriortosurgerywereassociatedwithlower
CHESTRADIOGRAPH ratesofpostoperativecomplications.

PULMONARYFUNCTIONTESTS Evaluatingfortobaccouseandofferingstrategiestoquit
INFORMATIONFORPATIENTS smokingmayreduceriskofpostoperativewoundandpulmonary
complications.(See"Managementofsmokingcessationin
SUMMARYAND
RECOMMENDATIONS
REFERENCES
REFERENCES adults"and"Smokingcessationcounselingstrategiesinprimary
GRAPHICSViewAll care".)

TABLES
Probabilityabnormaltest
Predictivevaluepositivetests
Likelihoodratiospreoptests LABORATORYEVALUATIONSeveralreviewarticlesin
Preopevaluationquestions perioperativeconsultationandmostlocalinstitutionalpolicies
ASAclassification(expanded supportaselectiveapproachtopreoperativetesting[3,6,16,36
version) 39].ApracticeadvisoryfromtheAmericanSocietyof
AUDITC AnesthesiologistsandasafetyguidelinefromtheAssociationof
ACCAHApreoperativeECG AnaesthetistsofGreatBritainandIrelandrecommendagainst
routinepreoperativelaboratorytestingintheabsenceofclinical
RELATEDTOPICS
indications[36,40].
HelpimproveUpToDate.DidUpToDateansweryourquestion? Yes No
Diagnosisandclinical
TimingoflaboratorytestingWhenlaboratorytestsarefelt
19.3 tobenecessary,itisprobablysafetousetestresultsthatwere
performedandwerenormalwithinthepastfourmonths,unless
therehasbeenaninterimchangeinclinicalstatus.Thevalidity
ofthisapproachwasillustratedinanobservationalstudywhich
Preoperativemedicalevaluationofthehealthypatient Find Patient Print

investigatedtheusefulnessof7549preoperativetestsperformed
TOPICOUTLINE in1109patientsundergoingelectivesurgery[37].Thetests
wereduplicatesofthoseperformedwithintheyearpriorto
INTRODUCTION
surgeryin47percentofcases:
RATIONALEFORSELECTIVE
TESTING Of3096previousresultsthatwerenormal(asdefinedby
Predictivevalue hospitalreferencerange)andperformedclosesttothe
CLINICALEVALUATION timeofbutbeforeadmission(medianintervaltwo
Screeningquestionnaire months),only13(0.4percent)valueswereoutsidea
Age rangeconsideredacceptableforsurgery.Mostofthese
Exercisecapacity abnormalitieswerepredictablefromthepatient'shistory,
Medicationuse andmostwerenotnotedinthemedicalrecord.
Obesity Incontrast,of461previousteststhatwereabnormal,78
Alcoholmisuse (17percent)repeatvaluesatadmissionwereoutsidea
Smoking rangeconsideredacceptableforsurgery,suggestingthat
LABORATORYEVALUATION teststhathaverecentlybeenabnormalshouldberepeated
Timingoflaboratorytesting preoperatively.
Laboratorystudies
Completebloodcount LaboratorystudiesWhilepreoperativelaboratorytestingis
notroutinelyindicated,selectivetestingisappropriateinspecific
Renalfunction
circumstances,includingpatientswithknownunderlying
Electrolytes
diseasesorriskfactorsthatwouldaffectoperativemanagement
Bloodglucose
orincreaserisk,andspecifichighrisksurgicalprocedures.
Liverfunctiontests
Specificlaboratorystudiescommonlyorderedforpreoperative
Testsofhemostasis
evaluationincludeacompletebloodcount,electrolytes,renal
Urinalysis function,bloodglucose,liverfunctionstudies,hemostasis
Pregnancytesting evaluation,andurinalysis[38].Thesetestsarediscussedbelow
ELECTROCARDIOGRAM withindicationsfortheiruseinspecificpopulationsand
CHESTRADIOGRAPH surgeries.
PULMONARYFUNCTIONTESTS CompletebloodcountAnemiaispresentin
INFORMATIONFORPATIENTS approximately1percentofasymptomaticpatientssurgically
SUMMARYAND significantanemiahasanevenlowerprevalence[3].However,
RECOMMENDATIONS anemiaiscommonfollowingmajorsurgeryandthepreoperative
REFERENCES
REFERENCES hemoglobinlevelpredictspostoperativemortality.Asan
GRAPHICSViewAll example,alargeobservationalstudyofolderveterans(n=
310,311,age65years)foundanincreasein30day
TABLES
postoperativemortalityforpatientswithmildlyabnormal
Probabilityabnormaltest preoperativehematocritsundergoingmajornoncardiacsurgery,
Predictivevaluepositivetests evenintheabsenceofsignificantbloodloss[41].Adjusted
Likelihoodratiospreoptests mortalityincreasedby1.6percent(95%CI1.1to2.2percent)
Preopevaluationquestions foreveryonepercentagepointincreaseordecreasefroma
ASAclassification(expanded normalhematocrit,definedas39.0to53.9percent.Thedata
version) cannotdistinguishwhetheranabnormalhematocritservesasa
AUDITC markerforcoexistentdiseasethatincreasesmortalityrisk,or
ACCAHApreoperativeECG whethertheanemiaitselfincreasesphysiologicstressesand
thereforecomplicationrates.Thus,itisuncleariftheincreased
RELATEDTOPICS
riskismodifiablebyinterventionsaimedatcorrectingthe
HelpimproveUpToDate.DidUpToDateansweryourquestion? Yes No
Diagnosisandclinical hematocrit.

19.3 Abaselinehemoglobinmeasurementissuggestedforallpatients
65yearsofageorolderwhoareundergoingmajorsurgery,and
foryoungerpatientsundergoingmajorsurgerythatisexpected
toresultinsignificantbloodloss.Incontrast,hemoglobin
Preoperativemedicalevaluationofthehealthypatient Find Patient Print

measurementisnotnecessaryforthoseundergoingminor
TOPICOUTLINE surgeryunlessthehistorysuggestsanemia.

INTRODUCTION Thefrequencyofsignificantunsuspectedwhitebloodcellor
RATIONALEFORSELECTIVE plateletabnormalitiesislow[3].Unlikethehemoglobin
TESTING concentration,however,thereislittlerationaletosupport
Predictivevalue baselinetestingofeither.Nevertheless,obtainingacomplete
bloodcount,includingwhitecountandplateletmeasurement,
CLINICALEVALUATION
canberecommendedifthecostisnotsubstantiallygreaterthan
Screeningquestionnaire
thecostofahemoglobinconcentrationalone.Theremaybe
Age
somecostsincurredduetofollowupoffalsepositiveresults
Exercisecapacity however,withrespecttoplateletcounts,thesecostsdonot
Medicationuse appeartobesubstantial[42].
Obesity
Alcoholmisuse RenalfunctionMildtomoderaterenalimpairmentis
Smoking usuallyasymptomatictheprevalenceofanelevatedcreatinine
amongasymptomaticpatientswithnohistoryofrenaldiseaseis
LABORATORYEVALUATION
only0.2percent[3,5].However,theprevalenceincreaseswith
Timingoflaboratorytesting
age.Inonestudy,forexample,theprevalenceamong
Laboratorystudies unselectedpatientsaged46to60was9.8percent[43].
Completebloodcount
Renalfunction Intherevisedcardiacriskindex,aserumcreatinine>2.0mg/dL
Electrolytes (177mol/L)wasoneofsixindependentfactorsthatpredicted
Bloodglucose postoperativecardiaccomplications[44].Renalinsufficiencyis
alsoanindependentriskfactorforpostoperativepulmonary
Liverfunctiontests
complications[11]andamajorpredictorofpostoperative
Testsofhemostasis
mortality[45].Renalinsufficiencynecessitatesdosage
Urinalysis
adjustmentofsomemedicationsthatmaybeused
Pregnancytesting
perioperatively(eg,musclerelaxants).
ELECTROCARDIOGRAM
Forthesereasons,itisreasonabletoobtainaserumcreatinine
CHESTRADIOGRAPH
concentrationinpatientsovertheageof50undergoing
PULMONARYFUNCTIONTESTS
intermediateorhighrisksurgery,althoughthereisnoclear
INFORMATIONFORPATIENTS consensusonthispoint.Itshouldalsobeorderedwhen
SUMMARYAND hypotensionislikely,orwhennephrotoxicmedicationswillbe
RECOMMENDATIONS used.
REFERENCES
REFERENCES

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TABLES
Probabilityabnormaltest
Predictivevaluepositivetests
Likelihoodratiospreoptests ElectrolytesThefrequencyofunexpectedelectrolyte
Preopevaluationquestions abnormalitiesislow(0.6percentinonereport)[3].Inaddition,
ASAclassification(expanded therelationshipbetweenmostofthesederangementsand
version) operativemorbidityisnotclear.Furthermore,clinicianscan
AUDITC predictmostabnormalitiesbasedonhistory(forexample,
ACCAHApreoperativeECG currentuseofadiuretic,angiotensinconvertingenzyme(ACE)
inhibitor,orangiotensinreceptorblocker(ARB),orknown
RELATEDTOPICS
chronicrenalinsufficiency).
HelpimproveUpToDate.DidUpToDateansweryourquestion? Yes No
Diagnosisandclinical
Thus,routineelectrolytedeterminationsareNOTrecommended
19.3 unlessthepatienthasahistorythatincreasesthelikelihoodof
anabnormality.

BloodglucoseThefrequencyofglucoseabnormalities
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increaseswithagealmost25percentofpatientsoverage60
Print

hadanabnormalvalueinonereport[43].Mostcontrolled
TOPICOUTLINE
studieshavenotfoundarelationshipbetweenoperativeriskand
INTRODUCTION diabetes[8,43],exceptinpatientsundergoingvascularsurgery
RATIONALEFORSELECTIVE orcoronaryarterybypassgrafting[46,47].Whiletherevised
TESTING cardiacriskindexidentifieddiabetesasariskfactorfor
Predictivevalue postoperativecardiaccomplications,onlypatientswithinsulin
treateddiabeteswereatrisk[44].Thereisnoevidencethat
CLINICALEVALUATION
asymptomatichyperglycemia,inapatientnotpreviouslyknown
Screeningquestionnaire
tohavediabetes,increasessurgicalrisk.Therateof
Age
asymptomatichyperglycemiainunselectedsurgicalpatientsis
Exercisecapacity
lowinonereporttheincidencewasonly1.2percent[48].
Medicationuse
Obesity Unexpectedabnormalbloodglucoseresultsdonotoften
Alcoholmisuse influenceperioperativemanagement.Asanexample,onestudy
Smoking evaluatedthebenefitofroutinelaboratorytestingin1010
presumablyhealthypatientsundergoingcholecystectomy[5].
LABORATORYEVALUATION
Eightpatientshadunexpectedelevationsinpreoperativeserum
Timingoflaboratorytesting
glucoseonlyoneofthesepatientsdevelopedsignificant
Laboratorystudies
postoperativehyperglycemiaandthiswasnotrecognizeduntil
Completebloodcount aftertotalparenteralnutritionwasstarted.Nopatientinthis
Renalfunction studybenefitedfromroutinepreoperativemeasurementof
Electrolytes serumglucose.
Bloodglucose
Liverfunctiontests Thus,routinemeasurementofbloodglucoseisNOT
recommendedforpreoperativehealthypatients.
Testsofhemostasis
Urinalysis LiverfunctiontestsUnexpectedliverenzyme
Pregnancytesting abnormalitiesareuncommon,occurringinonly0.3percentof
ELECTROCARDIOGRAM patientsinoneseries[4].Inapooleddataanalysis,only0.1
CHESTRADIOGRAPH percentofallroutinepreoperativeliverfunctiontestschanged
preoperativemanagement(table3)[6].Severeliverfunction
PULMONARYFUNCTIONTESTS
testabnormalitiesamongpatientswithcirrhosisoracuteliver
INFORMATIONFORPATIENTS diseaseareassociatedwithincreasedsurgicalmorbidityand
SUMMARYAND mortality,butitisnotclearifmildabnormalitiesamongpatients
RECOMMENDATIONS withnoknownliverdiseasehaveasimilarimpact[49].
REFERENCES
REFERENCES Clinicallysignificantliverdiseasewouldmostlikelybesuspected
GRAPHICSViewAll onthebasisofthehistoryandphysicalexaminationthus,
routineliverenzymetestingisNOTrecommended.
TABLES
Probabilityabnormaltest
Predictivevaluepositivetests
Likelihoodratiospreoptests TestsofhemostasisUnexpectedsignificantabnormalities
Preopevaluationquestions oftheprothrombintime(PT)orpartialthromboplastintime(PTT)
ASAclassification(expanded areuncommon[3,42].Inheritedcoagulationdefectsarequite
version) rare.Forexample,theincidenceofhemophiliaAandBamong
AUDITC menis1:5000and1:30000respectively[50].Nearlyallof
ACCAHApreoperativeECG thesecaseswouldbeevidentbasedonclinicalpresentationprior
tothepreoperativemedicalevaluation.Inaddition,the
RELATEDTOPICS
relationshipbetweenanabnormalresultandtheriskof
HelpimproveUpToDate.DidUpToDateansweryourquestion? Yes No
Diagnosisandclinical perioperativehemorrhageisnotwelldefined,butappearstobe
low,particularlyinthosewhoarethoughttohavealowriskof
19.3
hemorrhageonthebasisofhistoryandphysicalexamination
[51,52].Inapooleddataanalysis,anabnormalPThada
positivelikelihoodratioof0forpredictingapostoperative
Preoperativemedicalevaluationofthehealthypatient Find Patient
complication,andanegativelikelihoodratioof1.01(table3)in

Print

nocasedidthefindingofanabnormalPTchangepatient
TOPICOUTLINE managementormodifythelikelihoodofacomplication[6].
INTRODUCTION Similarly,thebleedingtimeisnotusefulinassessingtheriskof
RATIONALEFORSELECTIVE perioperativehemorrhage[53,54].
TESTING Thus,routinepreoperativetestsofhemostasisareNOT
Predictivevalue recommended.Weadvisetestinginpatientswithaknown
CLINICALEVALUATION personalorfamilyhistoryofbleedingdiathesis,oranillness
Screeningquestionnaire associatedwithbleedingtendency[55].
Age
Theroleofpreoperativehemostasisevaluationinpatients
Exercisecapacity
undergoingintermediatetohighrisksurgicalproceduresis
Medicationuse somewhatcontroversial.WesuggestNOTperformingPTandPTT
Obesity insuchpatients.Others,includingauthorsforUpToDate,have
Alcoholmisuse suggestedtestingallpatientsundergoingintermediatetohigh
Smoking risksurgicalprocedures,ascliniciansmayforgettoaskabout
LABORATORYEVALUATION bleeding,orpatienthistorymaybeunreliable.Asdiscussed
Timingoflaboratorytesting above,thereisnoevidencetosupportthispractice.(See
Laboratorystudies "Preoperativeassessmentofhemostasis".)
Completebloodcount UrinalysisThetheoreticalreasontoobtainapreoperative
Renalfunction urinalysisisdetectionofunsuspectedrenaldiseaseand/or
Electrolytes urinarytractinfection.Asymptomaticrenaldiseasecanbe
Bloodglucose detectedbymeasurementofserumcreatinineinselected
Liverfunctiontests patients(see'Renalfunction'above).
Testsofhemostasis
Urinarytractinfectionshavethepotentialtocausebacteremia
Urinalysis
andpostsurgicalwoundinfections,particularlywithprosthetic
Pregnancytesting
surgery[56].Patientswithpositiveurinalysisandurineculture
ELECTROCARDIOGRAM aregenerallytreatedwithantibioticsandproceedwithsurgery
CHESTRADIOGRAPH withoutdelay[57].However,itisunclearwhetherapositive
PULMONARYFUNCTIONTESTS preoperativeurinalysisandculturewithsubsequentantibiotic
INFORMATIONFORPATIENTS treatmentpreventpostsurgicalinfection.Onestudyfoundno
differenceinwoundinfectionbetweenpatientswithnormaland
SUMMARYAND
abnormalurinalysis[58].Anotherstudyfoundthatpatientswith
RECOMMENDATIONS
asymptomaticurinarytractinfectiondetectedbyurinalysishad
REFERENCES
REFERENCES anincreasedriskofwoundinfectionpostoperatively,despite
GRAPHICSViewAll treatment[59].

TABLES Acosteffectivenessanalysisestimatedthat4.58wound
Probabilityabnormaltest infectionsinnonprosthetickneeoperationsmaybeprevented
Predictivevaluepositivetests annuallybytheuseofroutineurinalysis,atacostof
Likelihoodratiospreoptests $1,500,000perwoundinfectionprevented[60].
Preopevaluationquestions Thus,routineurinalysisisNOTrecommendedpreoperativelyfor
ASAclassification(expanded mostsurgicalprocedures.
version)
AUDITC PregnancytestingTheknowledgethatawomanis
ACCAHApreoperativeECG pregnantsubstantiallychangesperioperativemanagement.The
patientmayelecttocancelelectivesurgery,ormaydecidein
RELATEDTOPICS collaborationwithherphysicianstoundertakeadifferent,lower
HelpimproveUpToDate.DidUpToDateansweryourquestion?
risksurgerythanoriginallyplanned.Inaddition,anestheticYes No
Diagnosisandclinical
techniquediffersforpregnantwomen,andtheremayberisksto
19.3 thefetusifapregnancygoesundetectedbeforesurgeryand
anesthesia.

TheNationalPatientSafetyAgencyintheUnitedKingdom
Preoperativemedicalevaluationofthehealthypatient Find

Patient

Print
recommendstoalwayscheckwhetherawomanmaybe
pregnantbeforesurgery,andifpregnancyispossibleafter
TOPICOUTLINE
historytaking,toofferapregnancytest[61].TheAmerican
INTRODUCTION SocietyofAnesthesiologistsrecommendsthatcliniciansconsider
RATIONALEFORSELECTIVE pregnancytestingforallwomanofchildbearingage[36].While
TESTING theseguidelinesprovidesomediscretionindecidingwhich
Predictivevalue womentotest,itisoftennotpossibletoreliablyexclude
CLINICALEVALUATION pregnancybasedonmedicalhistorytakingalone[62].Many
institutionsrequirepregnancytestingforallreproductiveage
Screeningquestionnaire
womenbeforesurgery.Thereislowrisktothisapproachfalse
Age
positivesarerare,testingisinexpensive,andtheresultsreturn
Exercisecapacity
rapidly.Thus,wesuggestpregnancytestinginallreproductive
Medicationuse
agewomenpriortosurgery.(See"Diagnosisandclinical
Obesity manifestationsofearlypregnancy",sectionon'Laboratory
Alcoholmisuse tests'.)
Smoking
ELECTROCARDIOGRAMElectrocardiograms(ECGs)havea
LABORATORYEVALUATION
lowlikelihoodofchangingperioperativemanagementinthe
Timingoflaboratorytesting
absenceofknowncardiacdisease.Nevertheless,detectinga
Laboratorystudies
recentmyocardialinfarctionisimportantsinceitisassociated
Completebloodcount
withhighsurgicalmorbidityandmortality[8].(See"Estimation
Renalfunction ofcardiacriskpriortononcardiacsurgery".)
Electrolytes
Bloodglucose TheprevalenceofabnormalECGsincreaseswithage[63].
Liverfunctiontests ImportantECGabnormalitiesinpatientsyoungerthan45years
Testsofhemostasis withnoknowncardiacdiseaseareveryinfrequent.
Urinalysis Theelectrocardiogramalonemaybeapooroverallpredictorof
Pregnancytesting postoperativecardiaccomplications[64].Ontheotherhand,a
ELECTROCARDIOGRAM preoperativeECGcanbeimportantasabaselinetocomparewith
CHESTRADIOGRAPH postoperativeECGabnormalities.

PULMONARYFUNCTIONTESTS The2007AmericanCollegeofCardiology/AmericanHeart
INFORMATIONFORPATIENTS Association(ACC/AHA)GuidelinesonPerioperative
CardiovascularEvaluationstatethatECGisnotusefulin
SUMMARYAND
RECOMMENDATIONS asymptomaticpatientsundergoinglowriskprocedures[16].

REFERENCES
REFERENCES Similarly,theEuropeanSocietyofCardiology2009preoperative
GRAPHICSViewAll guidelinesdonotrecommendECGinpatientswithoutriskfactors
[65].
TABLES
Probabilityabnormaltest The2007ACC/AHAguidelinesdorecommendapreoperative
Predictivevaluepositivetests resting12leadECGforselectedpatientsasfollows(table7):
Likelihoodratiospreoptests
Patientswithatleastoneclinicalriskfactorscheduledto
Preopevaluationquestions
undergovascularsurgery.Theseclinicalriskfactorsare
ASAclassification(expanded
ischemicheartdisease,compensatedorpriorheartfailure,
version)
cerebrovasculardisease,diabetes,andrenalinsufficiency.
AUDITC
ACCAHApreoperativeECG Patientsscheduledtoundergointermediaterisksurgery
withknowncardiovasculardisease,peripheralartery
RELATEDTOPICS
disease,orcerebrovasculardisease.
HelpimproveUpToDate.DidUpToDateansweryourquestion? Yes No
Diagnosisandclinical
TheACC/AHAgavealessstrongrecommendationtoperforman
19.3 ECGforpatientsscheduledtoundergovascularsurgerywithno
clinicalriskfactorsORthosescheduledtoundergointermediate
risksurgerywithatleastoneclinicalriskfactor.
Preoperativemedicalevaluationofthehealthypatient Find

Patient

Print
Itisuncertainwhetherthepreoperativeapproachtoobese
TOPICOUTLINE patientsshoulddifferfromthatofthegeneralpopulationin
regardtoECGs.TheAHA2009scientificadvisoryon
INTRODUCTION
cardiovascularevaluationandmanagementofseverelyobese
RATIONALEFORSELECTIVE patients(BMI40kg/m2)undergoingsurgerystatesthatan
TESTING ECGisreasonableinallobesepatientswithatleastonerisk
Predictivevalue factorforcoronaryheartdisease(diabetes,smoking,
CLINICALEVALUATION hypertension,orhyperlipidemia)orpoorexercisetolerance[66].
Screeningquestionnaire
CHESTRADIOGRAPHPreoperativechestxraysaddlittleto
Age
theclinicalevaluationinidentifyingpatientsatriskfor
Exercisecapacity perioperativecomplications[39].Abnormalfindingsonchestx
Medicationuse rayoccurfrequently,andaremoreprevalentinolderpatients.
Obesity Severalsystematicreviewsandindependentadvisory
Alcoholmisuse organizationsintheUSandEuroperecommendagainstroutine
Smoking chestradiographinhealthypatients[6770].
LABORATORYEVALUATION
Thereislittleevidencetosupporttheuseofapreoperativechest
Timingoflaboratorytesting
radiographregardlessofageunlessthereisknownorsuspected
Laboratorystudies cardiopulmonarydiseasefromthehistoryorphysical
Completebloodcount examination.Inametaanalysisof21studiesofroutinechest
Renalfunction radiography,amongatotalof14,390routinechestxrays,there
Electrolytes were1444abnormalstudies[71].Only140abnormalfindings
Bloodglucose wereunexpected,andonly14(0.1percent)ofallroutinechest
Liverfunctiontests xraysinfluencedmanagement.
Testsofhemostasis
Onestudyscreened905surgicaladmissionsforthepresenceof
Urinalysis
clinicalfactorsthatwerethoughttoberiskfactorsforan
Pregnancytesting
abnormalpreoperativechestxray[72].Theriskfactorsincluded
ELECTROCARDIOGRAM ageover60years,orclinicalfindingsconsistentwithcardiacor
CHESTRADIOGRAPH pulmonarydisease.Noriskfactorswereevidentin368patients
PULMONARYFUNCTIONTESTS ofthese,onlyone(0.3percent)hadanabnormalchestxray,
whichdidnotaffectthesurgery.Ontheotherhand,504
INFORMATIONFORPATIENTS
patientshadidentifiableriskfactorsofthese,114(22percent)
SUMMARYAND
hadsignificantabnormalitiesonpreoperativechestxray.
RECOMMENDATIONS
REFERENCES
REFERENCES Whileroutinepreoperativechestxraysarenotindicated,we
GRAPHICSViewAll agreewiththeAmericanCollegeofPhysicians(ACP)
recommendationforchestxraysinpatientswith
TABLES
cardiopulmonarydiseaseandthoseolderthan50yearsofage
Probabilityabnormaltest whoareundergoingabdominalaorticaneurysmsurgeryorupper
Predictivevaluepositivetests abdominal/thoracicsurgery[11].Posteroanteriorandlateral
Likelihoodratiospreoptests chestxrayisalsosuggestedbytheAmericanHeartAssociation
Preopevaluationquestions forpatientswithsevereobesity(BMI40kg/m2)[66].Inthese
ASAclassification(expanded patients,thechestradiographmayindicateundiagnosedheart
version) failure,cardiacchamberenlargement,orabnormalpulmonary
AUDITC vascularitysuggestiveofpulmonaryhypertension,warranting
ACCAHApreoperativeECG furthercardiovascularinvestigation.Therelationshipbetween
findingsonchestxrayandperioperativemorbidityarenotwell
RELATEDTOPICS
definedinthesepopulations,however,andstudiesarenot
HelpimproveUpToDate.DidUpToDateansweryourquestion? Yes No
Diagnosisandclinical availablethatindicatethatpreoperativeradiographychanges
perioperativeoutcomes.Thus,wedonotsuggestroutinechest
19.3 xraysinseverelyobesepatients.

PULMONARYFUNCTIONTESTSRoutinepulmonaryfunction
testsareNOTindicatedforhealthypatientspriortosurgery(see
Preoperativemedicalevaluationofthehealthypatient Find Patient Print

"Evaluationofpreoperativepulmonaryrisk").
TOPICOUTLINE
Thesetestsgenerallyshouldbereservedforpatientswhohave
INTRODUCTION dyspneathatremainsunexplainedaftercarefulclinical
RATIONALEFORSELECTIVE evaluation.Clinicalfindingsaremorepredictiveoftheriskof
TESTING postoperativepulmonarycomplicationthanarespirometric
Predictivevalue results[73].Thesefindingsincludedecreasedbreathsounds,
prolongedexpiratoryphase,rales,rhonchi,orwheezes.
CLINICALEVALUATION
Screeningquestionnaire INFORMATIONFORPATIENTSUpToDateofferstwotypesof
Age patienteducationmaterials,TheBasicsandBeyondthe
Exercisecapacity Basics.TheBasicspatienteducationpiecesarewritteninplain
Medicationuse language,atthe5 thto6 thgradereadinglevel,andtheyanswer
Obesity thefourorfivekeyquestionsapatientmighthaveaboutagiven
Alcoholmisuse condition.Thesearticlesarebestforpatientswhowanta
Smoking generaloverviewandwhoprefershort,easytoreadmaterials.
BeyondtheBasicspatienteducationpiecesarelonger,more
LABORATORYEVALUATION
sophisticated,andmoredetailed.Thesearticlesarewrittenat
Timingoflaboratorytesting
the10 thto12 thgradereadinglevelandarebestforpatientswho
Laboratorystudies
wantindepthinformationandarecomfortablewithsome
Completebloodcount
medicaljargon.
Renalfunction
Electrolytes Herearethepatienteducationarticlesthatarerelevanttothis
Bloodglucose topic.Weencourageyoutoprintoremailthesetopicstoyour
Liverfunctiontests patients.(Youcanalsolocatepatienteducationarticlesona
Testsofhemostasis varietyofsubjectsbysearchingonpatientinfoandthe
keyword(s)ofinterest.)
Urinalysis
Pregnancytesting
Basicstopic(see"Patientinformation:Questionstoaskif
ELECTROCARDIOGRAM youarehavingaprocedureorsurgery(TheBasics)")
CHESTRADIOGRAPH
PULMONARYFUNCTIONTESTS SUMMARYANDRECOMMENDATIONSTheoverallriskof
surgeryislowinhealthyindividuals.Preoperativetestsusually
INFORMATIONFORPATIENTS
leadtofalsepositiveresults,unnecessarycosts,andapotential
SUMMARYAND delayofsurgery.Preoperativetestsshouldnotbeperformed
RECOMMENDATIONS unlessthereisaclearclinicalindication.
REFERENCES
REFERENCES
Asimplescreeningquestionnairecanbehelpfulinthe
GRAPHICSViewAll preoperativeevaluation(table4).Importantpotentialrisk
TABLES factorstodiscusswiththepatientincludeage,exercise
capacity,alcohol,smoking,andmedicationuse.Obesityis
Probabilityabnormaltest
notariskfactorformostmajoradversepostoperative
Predictivevaluepositivetests
outcomesinpatientsundergoingnoncardiacsurgery.(See
Likelihoodratiospreoptests
'Clinicalevaluation'above.)
Preopevaluationquestions
ASAclassification(expanded Routinepreoperativelaboratorytestshavenotbeenshown
version) toimprovepatientoutcomesamonghealthypatients
AUDITC undergoingsurgery.Inaddition,routinetestinginhealthy
ACCAHApreoperativeECG patientshaspoorpredictivevalue,leadingtofalsepositive
testresultsand/orincreasedmedicolegalriskfornot
RELATEDTOPICS
followinguponabnormaltestresults(see'Rationalefor
HelpimproveUpToDate.DidUpToDateansweryourquestion? Yes No
Diagnosisandclinical selectivetesting'above).

19.3 Wesuggestbaselinehemoglobinmeasurementforall
patients65yearsofageorolderwhoareundergoing
majorsurgeryandforyoungerpatientsundergoing
surgerythatisexpectedtoresultinsignificantbloodloss
Preoperativemedicalevaluationofthehealthypatient Find Patient Print

(Grade2C).Forotherhealthypatients,wesuggestNOT
TOPICOUTLINE performingroutinehemoglobin,whitebloodcount,or
plateletmeasurements(Grade2B).(See'Completeblood
INTRODUCTION
count'above.)
RATIONALEFORSELECTIVE
TESTING Intherevisedcardiacriskindex,aserumcreatinine>2.0
Predictivevalue mg/dL(177mol/L)predictedpostoperativecardiac
CLINICALEVALUATION complications.WesuggestNOTobtainingaserum
Screeningquestionnaire creatinineconcentration,exceptinthefollowingpatients
(Grade2B)(see'Renalfunction'above):
Age
Exercisecapacity
Patientsovertheageof50undergoingintermediateor
Medicationuse
highrisksurgery.
Obesity
Youngerpatientssuspectedofhavingrenaldisease,
Alcoholmisuse
whenhypotensionislikelyduringsurgery,orwhen
Smoking
nephrotoxicmedicationswillbeused.
LABORATORYEVALUATION
Timingoflaboratorytesting WesuggestNOTtestingforserumelectrolytes,blood
Laboratorystudies glucose,liverfunction,hemostasis,orurinalysisinthe
Completebloodcount healthypreoperativepatient(Grade2B).Wesuggest
Renalfunction pregnancytestinginallreproductiveagewomenpriorto
Electrolytes surgery,ratherthanuseofhistorytakingaloneto
Bloodglucose determinepregnancy(Grade2C).(See'Laboratory
Liverfunctiontests studies'above.)
Testsofhemostasis
WesuggestNOTorderinganECGforasymptomatic
Urinalysis
patientsundergoinglowrisksurgicalprocedures(Grade
Pregnancytesting
2B).Inaccordwiththe2007ACC/AHAguidelines,we
ELECTROCARDIOGRAM suggesta12leadECGinpatientswithoutperioperative
CHESTRADIOGRAPH clinicalriskfactorwhorequirevascularsurgicalprocedures
PULMONARYFUNCTIONTESTS (Grade2C).Inaddition,a12leadECGispartofthe
evaluationinpatientswithpreexistingcardiovascular
INFORMATIONFORPATIENTS
diseasewhoareundergoingsurgeryandinseverelyobese
SUMMARYAND
patientswithpoorefforttoleranceoratleastoneadditional
RECOMMENDATIONS
cardiovascularriskfactor.Thisisdiscussedindetail
REFERENCES
REFERENCES elsewhere.(See"Estimationofcardiacriskpriorto
GRAPHICSViewAll noncardiacsurgery",sectionon'Resting
electrocardiogram'and'Electrocardiogram'above.)
TABLES
Probabilityabnormaltest WesuggestthatcliniciansNOTorderroutinepreoperative
Predictivevaluepositivetests chestxraysorpulmonaryfunctiontestsinthehealthy
Likelihoodratiospreoptests patient(Grade2B).Wesuggestobtainingapreoperative
Preopevaluationquestions chestxrayinpatientswithcardiopulmonarydiseaseand
ASAclassification(expanded thoseolderthan50yearsofagewhoareundergoing
version) abdominalaorticaneurysmsurgeryorupper
AUDITC abdominal/thoracicsurgery(Grade2C).(See'Chest
ACCAHApreoperativeECG radiograph'aboveand'Pulmonaryfunctiontests'above.)

RELATEDTOPICS

Diagnosisandclinical UseofUpToDateissubjecttotheSubscriptionandLicense
HelpimproveUpToDate.DidUpToDateansweryourquestion? Yes No
Agreement.
19.3

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Preoperativemedicalevaluationofthehealthypatient Find

Patient

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HelpimproveUpToDate.DidUpToDateansweryourquestion? Yes No
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19.3 cardiovascularevaluationandcarefornoncardiacsurgery:
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Preoperativemedicalevaluationofthehealthypatient Find Patient Print

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Completebloodcount 22.ZachariasA,SchwannTA,RiordanCJ,etal.Obesityand
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INTRODUCTION preoperativeabstinenceonpoorpostoperativeoutcomein
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Age
35.MillsE,EyawoO,LockhartI,etal.Smokingcessation
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Obesity
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RELATEDTOPICS
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Diagnosisandclinical

19.3

Preoperativemedicalevaluationofthehealthypatient Find

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TOPICOUTLINE

INTRODUCTION
RATIONALEFORSELECTIVE
TESTING
Predictivevalue
CLINICALEVALUATION
Screeningquestionnaire
Age
Exercisecapacity
Medicationuse
Obesity
Alcoholmisuse
Smoking
LABORATORYEVALUATION
Timingoflaboratorytesting
Laboratorystudies
Completebloodcount
Renalfunction
Electrolytes
Bloodglucose
Liverfunctiontests
Testsofhemostasis
Urinalysis
Pregnancytesting
ELECTROCARDIOGRAM
CHESTRADIOGRAPH
PULMONARYFUNCTIONTESTS
INFORMATIONFORPATIENTS
SUMMARYAND
RECOMMENDATIONS
REFERENCES