Pre-Op Medical Clearance for Surgery is generally asked to assess preoperative risk in most patients who are to undergo major surgery in high-risk patients. A general systems examination should identify obvious abnormalities:
- Cardiovascular system – heart murmur. Apart from emergency surgery, patients should be hemodynamically stable and their vital signs normal before starting anesthesia.
- Respiratory system – abnormal breath sounds.
- Gastrointestinal system – abdominal masses, previous scars.
- Musculoskeletal system – skeletal malformations such as kyphoscoliosis.
- General – local skin infection.
Routine preoperative testing (preoperative screening) of healthy people undergoing elective surgery is not recommended. Instead, a selective strategy, as outlined above, is safe and cost-effective as long as a complete history and physical examination are obtained. Based on the available evidence, the authors recommend the following preoperative tests:
- Hemoglobin level for major surgery with significant expected blood loss or in patients 65 years or older
- Serum creatinine level for people older than 50 years
- Pregnancy testing in all reproductive-age group women.
- ECG in patients undergoing high-risk surgery (e.g., vascular surgery) or intermediate-risk surgery and with at least one risk factor
- Stress test in patients older than 50 years
No laboratory test must be repeated if results were normal within 4 months of the surgery and no change in the patient’s clinical status occurred.
These investigations can be helpful to stratify risk, direct anesthetic choices, and guide postoperative management, but often are obtained because of protocol rather than medical necessity. The decision to order preoperative tests should be guided by the patient’s clinical history, comorbidities, and physical examination findings. Patients with signs or symptoms of active cardiovascular disease should be evaluated with appropriate testing, regardless of their preoperative status.
Electrocardiography is recommended for patients undergoing high-risk surgery and those undergoing intermediate-risk surgery who have additional risk factors. Patients undergoing low-risk surgery do not require electrocardiography. Chest radiography is reasonable for patients at risk of postoperative pulmonary complications if the results would change perioperative management. Preoperative urinalysis is recommended for patients undergoing invasive urologic procedures and those undergoing implantation of foreign material. Electrolyte and creatinine testing should be performed in patients with underlying chronic disease and those taking medications that predispose them to electrolyte abnormalities or renal failure.
Random glucose testing should be performed in patients at high risk of undiagnosed diabetes mellitus. In patients with diagnosed diabetes, A1C testing is recommended only if the result would change perioperative management. A complete blood count is indicated for patients with diseases that increase the risk of anemia or patients in whom significant perioperative blood loss is anticipated. Coagulation studies are reserved for patients with a history of bleeding or medical conditions that predispose them to bleeding, and for those taking anticoagulants. Patients in their usual state of health who are undergoing cataract surgery do not require preoperative testing.