Preoperative evaluation: A time-saving algorithm

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Applied Evidence

Preoperative evaluation: A time-saving algorithm

J Fam Pract. 2016 October;65(10):702-704,706-710

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References

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2. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. J Am Coll Cardiol. 2014;64:e77-e137.

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Optimize preventive care

Begin by ensuring that blood pressure (BP) and cholesterol are managed according to ACC/AHA guidelines. Then consider whether to start preoperative medications. You'll also want to screen for sleep apnea and discuss smoking status and cessation, if appropriate.

Initiate medications preoperatively?

In addition to having value as long-term primary prevention, there is some evidence that statins help prevent cardiac events during surgery. A randomized trial of over 200 vascular surgery patients showed that starting statins an average of 30 days prior to surgery significantly reduced cardiac complications.¹³ Another systematic review demonstrated that preoperative statins significantly reduce acute kidney injury from surgery.¹⁴

Unlike statins, aspirin started prior to surgery does not confer benefit. Aspirin was shown to significantly increase bleeding risk without improving cardiac outcomes in a large trial.¹⁵

Screen for sleep apnea

Sleep apnea increases the rate of respiratory failure between 2 and 3 times and the rate of cardiac complications about 1.5 times.¹⁶ This is a potentially correctable risk factor. The European Society of Anaesthesiology recommends clinical screening for obstructive sleep apnea using the STOP-Bang screening tool⁵ (TABLE 2⁴). For its part, the ASA combines screening questions from the STOP-Bang screening questionnaire with a review of the medical record and physical exam, because the STOP-Bang questionnaire alone has an insufficient negative predictive value, ranging from 30% and 82%.⁶ Obstructive sleep apnea is not addressed on published pulmonary and cardiac risk tools.^2,3,7,8

The evidence for CPAP is mixed. The evidence for continuous positive airway pressure (CPAP) to prevent postoperative complications is mixed. Larger cohort studies show that preoperative and postoperative CPAP decreases the risk of pulmonary and cardiac complications, but the few small randomized controlled trials that have been conducted show no significant benefit.¹⁷

Is the patient a smoker?

Smoking is a reversible risk factor for pulmonary, cardiac, and infectious complications, as well as overall mortality. Perioperative smoking cessation counseling has been complicated by concerns that stopping smoking within 8 weeks of surgery might worsen postoperative outcomes. A study that looked at intraoperative sputum retrieved via tracheal suction showed that patients who had stopped smoking for 2 months or more prior to surgery had the same amount of sputum as non-smokers, while those that quit smoking <2 months before surgery were more likely to have increased intraoperative sputum volume.¹⁸ This study did not demonstrate a difference in postoperative pulmonary complications, likely because it included patients receiving minor surgeries only. But based on this study, a cessation period of 2 months was often recommended.

A recent systematic review showed that smoking cessation shortly before surgery does not increase risk.¹⁹ In fact, although the review did not show a statistically significant reduction in postoperative complications among recent quitters as compared with continued smokers, there was a trend toward a reduction in overall complications with only a slight increase in pulmonary complications.¹⁹

Address potential pulmonary complications

In addition to screening for issues that could lead to cardiac complications, it’s important to address the potential for pulmonary complications. Postoperative pulmonary complications are at least as common as cardiac complications, and include all possible respiratory related outcomes of surgery, from pneumonia to respiratory failure.

During the preoperative evaluation, verify that BP and cholesterol are managed per ACC/AHA guidelines.

The seminal study on postoperative pulmonary complications is a systematic review published in 2006, which showed that the most important risk factors were surgery type, advanced age, ASA classification of overall health ≥II, and congestive heart failure.³ Chronic lung diseases and cigarette use were less predictive of pulmonary issues. All of these factors are included in the ACS NSQIP risk calculator.