UPDATE ARTICLE


https://doi.org/10.5005/jp-journals-10100-6105
Bengal Physician Journal
Volume 6 | Issue 1 | Year 2019

Preoperative Physician Fitness


Udas C Ghosh1, Kaushik Hazra2

1Department of Medicine, Murshidabad Medical College, Berhampopre, Murshidabad, West Bengal, India
2Department of Medicine, Jagannath Gupta Institute of Medical Sciences and Hospital, Budge Budge, West Bengal, India

Corresponding Author: Kaushik Hazra, Department of Medicine, Jagannath Gupta Institute of Medical Sciences and Hospital, Budge Budge, West Bengal, India, Phone: +91 9903073136, e-mail: drkaushik6@gmail.com

How to cite this article Ghosh UC, Hazra K. Preoperative Physician Fitness. Bengal Physician Journal 2019;6(1):17–20.

Source of support: Nil

Conflict of interest: None

ABSTRACT

A preoperative checkup is necessary for the patients who are preparing for surgery. The opinion of the internist is vital to decide the suitability of major and minor surgeries by assessing the health status of patients. There are different key parameters to be monitored and recorded, which includes a proper history, thorough clinical examination and an appropriate laboratory checkup. By assessing pre and perioperative risks, the role of physician is to optimize patient’s medical conditions to reduce morbidity and mortality. This article discusses these topics at length and provides some recommendations for fellow practitioners.

Keywords: General physicians, Laboratory checkup, Mortality, Preoperative.

INTRODUCTION

Adequate preoperative preparation and optimized treatment of preexisting diseases are very essential for a patient undergoing surgery to avoid peri and postoperative morbidity and or mortality and the person to take an active role to assess the possible complications during operation is a primary-care physician. So a systematic high-quality and cost-effective approach is needed for a safe surgery.1,2

These are the primary goals of a physician for a preoperative assessment:

GENERAL HEALTH ASSESSMENT

History

It is the most important component of preoperative evaluation. It includes thorough present, past, family, personal histories, drug history, including allergy to a drug (if any) to be taken.13

Physical Examination

It includes assessment of the airway, lungs, heart, and vital signs. Investigations are to be done for any significant finding in a physical examination.1,4

Drug History

A thorough drug history should be taken. Some drugs such as aspirin (at least 3 days before surgery), clopidogrel (7 days before surgery), and oral contraceptives (6 weeks before surgery) are to be stopped before surgery and some modification of dosage may be required such as antidiabetics and antihypertensive.

Laboratory Workup

Usually routine laboratory tests are not recommended for healthy individuals as a preoperative assessment. Depending upon the findings in clinical examination and history, laboratory tests are advised (Table 1).

Table 1: Indications of laboratory tests1,5
Complete blood count
  Major surgery
  Chronic cardiovascular, pulmonary, renal, hepatic disease, and malignancy
  Suspected anemia, bleeding prosthesis or myelosupression, less than one year of age
Coagulation profile (platelet count, INR, APTT)
  Anticoagulant therapy
  Bleeding prosthesis
  Liver disease
Electrolyte and creatinine
  Hypertension
  Renal disease
  Diabetes
  Pituitary or adrenal disease
  Digoxin or diuretic therapy
Fasting glucose
  Diabetes
Electrocardiogram
  Heart disease, hypertension, diabetes, sub-arachnoid, or intracranial bleeding, cerebrovascular accident, head trauma
Chest radiograph
  Cardiac or pulmonary disease

Source: Zambouri A. Preoperative evaluation and preparation for anesthesia and surgery. Hippokratia 2007;11(1):13–21

Complete Blood Count

Usually hemoglobin and hematocrit measurement are required before surgery, especially in a case of anemia or prolonged surgery with anticipated significant blood loss. It is also indicated in some preexisting chronic diseases such as chronic kidney disease, chronic liver disease, or any chronic inflammatory condition.6,7

Coagulation Testing

Coagulation tests such as platelet count, PT, and APTT are usually done before any major surgery and also in patients with impaired hemostasis or patients taking anticoagulants or in patients with a spontaneous bleeding history or a known family history of coagulopathy.68

Electrolyte and Creatinine Testing

Indicated usually in patients of hypertension, heart failure, chronic kidney disease, chronic liver disease, or in patients taking drugs such as diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, nonsteroidal anti-inflammatory drugs, and digoxin.

According to few guidelines, serum electrolyte assessment is indicated in patients aged more than 40 years but usually not followed if history and physical examinations are normal.6,7

Glucose and HbA1C Testing

In known diabetics or patients on medication such as corticosteroid or in patients with a history suggestive of undiagnosed diabetes, glucose and A1C measurement are indicated.68

Electrocardiography

Patients should have preoperative ECG before a high-risk or intermediate-risk surgical procedure. ECG is usually not indicated in patients undergoing low-risk procedures. Cardiac risk factors for noncardiac surgery are assessed68 (Table 2).

Chest Radiography69

Usually not indicated routinely in healthy patients but recommended as a preoperative assessment in known pulmonary or cardiac disease. Abnormal chronic findings in chest X-ray do not alter the outcome of surgery; so previous chest X-ray reports should also be assessed.

These are the risk factors of perioperative pulmonary complications:

  • Chronic obstructive pulmonary disease,
  • Age older than 60 years,
  • Functional dependence,
  • Congestive heart failure,
  • Emergency procedure,
  • Prolonged procedures.
Table 2: Surgery related risk of perioperative cardiac complications
Risk of procedureExamples
High (>5%)Aortic and major vascular surgery, peripheral vascular surgery
Intermediate (1–5%)Intraperitoneal or intrathoracic surgery, carotid endarterectomy, head and neck surgery, orthopedic surgery, prostate surgery
Low (%3C;1%)Ambulatory surgery, breast surgery, endoscopic procedures, superficial procedures, and cataract surgery

Source: Zambouri A. Preoperative evaluation and preparation for anesthesia and surgery. Hippokratia 2007;11(1):13–21

Urinalysis

Though routinely not recommended, it is suggested in patients undergoing surgical implantation of foreign material (like prosthetic joint, heart valve) or invasive urologic procedures.6,8

PERIOPERATIVE RISK ASSESSMENT1,10

Depending upon the risk associated with a surgery, there are some grading system. Among them one is ASA (American Society of Anesthesiologists) grading system, which is very simple and correlates the risk of anesthesia and surgery with patient’s general health and other comorbid conditions.

It is very useful and applied to almost all patients before surgery. Increased grading score is associated with increased pre- and peri-operative complications, especially in ASA class 4 and 5 (Table 3).

ASSESSMENT OF CARDIOVASCULAR RISK1,11

To assess the risk factors for noncardiac surgery, the American College of Cardiology (ACC) and the American Heart Association (AHA) have published guidelines for perioperative cardiovascular evaluation for noncardiac surgery.

Table 3: American Society of Anesthesiologists’ classification of physical status
ASA class 1
No organic, physiological, biochemical or psychiatric disturbances
ASA class 2
Mild-to-moderate systemic disturbance that may or may not be related to the reason of surgery (e.g. heart disease that only slightly limits physical activity, essential hypertension, diabetes mellitus, anemia, extremes of age, morbid obesity, and chronic bronchitis)
ASA class 3
Severe systemic disturbance that may or may not be related to the reason for surgery (does limit surgery), e.g. heart disease that limits activity, poorly controlled essential hypertension, diabetes mellitus with vascular complications, chronic pulmonary disease that limits activity, angina pectoris, and a history of prior myocardial infarction
ASA class 4
Severe systemic disturbance that is life-threatening with or without surgery—e.g. congestive heart failure, persistent angina pectoris, advanced pulmonary, renal, or hepatic dysfunction
ASA class 5
A moribund patient who has a little chance of survival but is submitted to surgery as a last resort (resuscitative effort)—e.g. uncontrolled hemorrhage as from a ruptured abdominal aneurysm, cerebral trauma, pulmonary embolus
ASA class 6
A declared brain-dead patient whose organs are being removed for donor purposes
E
An E is added to the status number to designate an emergency operation

Source: Zambouri A. Preoperative evaluation and preparation for anesthesia and surgery. Hippokratia 2007;11(1):13–21

These are:

ASSESSMENT OF PULMONARY RISK

Postoperative pulmonary complications are pneumonia, atelectasis, bronchitis, bronchospasm, and respiratory failure.

Risk factors are:1,12

PREVENTIVE STEPS TO AVOID THESE COMPLICATIONS

COPD/Asthma

For obstructive airway disease patients, the underlying conditions should be under controlled before surgery. There should be no wheezing and peak flow should be greater than 80% of predicted. If necessary, a short course of steroid (1 mg per kg body weight of prednisolone or other in equivalent doses) should be given. Patients with a recent history of hospitalization should be assessed more carefully as airway reactivity may persist for several weeks. COPD patients should be examined and investigated for corpulmonale. Impaired nutrition status and electrolyte imbalance should be corrected as they cause respiratory muscle weakness.

Diabetes Mellitus1,13

Diabetic patients are at greater risk than a nondiabetic as long-term complications of diabetic are more. There are some recommendations before surgery to prevent perioperative complications:

  • Blood glucose should be maintained below 180 mg/dL until oral feeding is started as blood glucose more than 180 g/dL (10 mmol/L) causes osmotic diuresis, dehydrations, and other complications.
  • OHA should be withheld on the day of surgery and may be stopped up to 48 hours after operation. To minimize the metabolic consequences of surgical stress, a combination of glucose and insulin should be given as per glycemic status. Usually in a 70 kg patient, 1 unit/hour regular insulin causes a decrease in blood glucose by approximately 25 to 30 mg/dL. In minor surgery, usually glucose insulin combination is not required.

PATIENTS ON ANTICOAGULATION1,14

It is very difficult to adjust the dosage of anticoagulation for a person undergoing surgery as a major concern is the increased risk of hemorrhage or thromboembolism after discontinuation of oral anticoagulation therapy. So there are some recommendations to avoid this complication:

PATIENTS RECEIVING ANTIPLATELET DRUGS

According to The American Society of Regional Anesthesia (ASRA) and European Societies, there are some recommendations for these patients to avoid major life-threatening bleeding complications during surgery and these are:

CONCLUSION

Assessment of a patient undergoing surgery is very important to avoid perioperative complications and the role of a physician is very crucial here. These are some recommendations of preoperative assessment and should be followed to decrease the morbidity and mortality of patients in significant amounts.

REFERENCES

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3. Pedersen T, Eliasen K, et al. A prospective study of mortality associated with anesthesia and surgery: risk indicators of mortality in hospital. Acta Anaesthesiol Scand 1990;34:176. DOI: 10.1111/j.1399-6576.1990.tb03066.x.

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9. Poldermans D, Bax JJ, et al. Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery; European Society of Cardiology (ESC). Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. Eur Heart J 2009;30(22):2769–2812. DOI: 10.1093/eurheartj/ehp337.

10. Fleisher LA. Risk of anesthesia. In: ed. RD. Miller ed., AnesthesiaPhiladelphia: Churchill-Livingstone; 2000. pp. 795–823.

11. Eagle KA, Berger PB, et al. ACC/AHA Guideline, Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery—Executive Summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Anesth Analg 2002;94:1052–1064. DOI: 10.1097/00000539-200205000-00002.

12. Warner MA, Offord KP, et al. Role of preoperative cessation of smoking and other factors in postoperative pulmonary complications: a blinded prospective study of coronary artery bypass patients. Mayo Clin Proc 1989;64:609–616. DOI: 10.1016/S0025-6196(12)65337-3.

13. Smetana GW. Current concepts: preoperative pulmonary evaluation. N Engl J Med 1999;340:937–944. DOI: 10.1056/NEJM199903253401207.

14. Rodgers A, Walker N, et al. Reduction of postoperative mortality and morbidity with epidural and spinal anesthesia: Results from overview of randomized trials. BMJ 2000;321:1–12. DOI: 10.1136/bmj.321.7275.1493.

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