Before surgery: Have you done enough to mitigate risk?

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Applied Evidence

Before surgery: Have you done enough to mitigate risk?

J Fam Pract. 2010 April;59(4):202-211

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References

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TABLE 1
Identifying—and minimizing—perioperative risk

Patient-specific risk factors	Procedure-specific risk factors	Risk reduction recommendations
Cardiac
Major risks • Decompensated HF • Severe valve disease • Significant arrhythmia • Unstable coronary syndrome Other cardiovascular risks • Cerebrovascular disease • CRF or AKI • Compensated/prior HF • Diabetes • Functional capacity <4 METS • Ischemic heart disease	Vascular surgery	• Optimize treatment of underlying conditions • Consider beta-blockers perioperatively^1,3,4 • Consider adjunctive testing if results could alter patient management
Pulmonary
• Acute URI • Requiring assistance with ADLs • Age >60 years • Elevated BUN (>21 mg/dL) • COPD • HF • Hypoalbuminemia (<35 g/L) • Presence of any systemic disease	• Emergency surgery • General anesthesia • Surgery >3 h • Abdominal, head or neck, thoracic, or vascular surgery • Neurosurgery	• Postop incentive spirometry • Postop nasogastric tube • Consider intraoperative use of LMA • Smoking cessation (30 days preoperatively)²⁸
Renal
• Age >60 years • CRF (especially with creatinine >2.1 mg/dL) • Diabetes (especially insulin-dependent) • HF • Jaundice	• Aortic or cardiovascular surgery • Liver transplantation	• Ensure preoperative euvolemia and good osmolar status • Minimize exposure to nephrotoxins • Avoid perioperative hypotension (maintain MAP >65 mm Hg) • Consider preoperative dialysis if GFR <15 mL/min¹⁴
Infectious
• Advanced age • Corticosteroid use • Hyperglycemia • Hypoalbuminemia • Immunocompromised • Malnutrition/obesity • Peripheral vascular disease • Postoperative incontinence • Preexisting infection • Prior radiation therapy • Smoking	• Blood transfusion • Surgery >3 h • Perioperative hypothermia • Perioperative hypoxia • Preoperative shaving • Prolonged preoperative hospital stay	• Optimize diabetes management (HbA1c <7); tight perioperative glycemic control • Treat preexisting infections • Provide nutritional supplementation (7-14 days preoperatively) • Smoking cessation (30 days preoperatively)²⁸
Hematologic: Perioperative bleeding
• Collagen vascular disease • GI or urogenital blood loss • Heavy or prolonged menses • Hematologic disease • Hemophilia or other inherited disorder • History of easy bruising or bleeding • Hypersplenism • Liver or renal disease • Severe bleeding after dental extraction, other surgery, or childbirth • Physical findings suggestive of purpura, hematoma, jaundice, or cirrhosis • Use of medications that affect hemostasis	• Minimal risk/JHSRCS 1 (eg, breast biopsy, carpal tunnel procedure, cataract surgery) • Mild risk/JHSRCS 2 (eg, laparoscopy, arthroscopy, inquinal hernia repair) • Moderate risk/JHSRCS 3 (eg, open abdominal procedure, arthroplasty) • Significant risk/JHSRCS 4 (eg, open thoracic surgery, major vascular/skeletal procedure)	• Optimize treatment of preexisting conditions • Discontinue antihemostatic medications, if medically feasible • Consider autologous blood banking
Hematologic: Perioperative anemia
• Hemoglobinopathies • Preexisting iron deficiency anemia • Preexisting pernicious anemia	• Risk of bleeding based on type of surgery (see Perioperative bleeding, above)	• Correct anemia prior to surgery • Consider preoperative erythropoietin • Avoid preoperative transfusion
Hematologic: Venous thromboembolism
• Acute medical illness • Age (older) • Cancer (active or occult); cancer therapy • Estrogen/SERMs • Erythropoiesis-stimulating agents • Immobility • IBD • Lower-extremity paresis • Myeloproliferative disorders • Nephrotic syndrome • Obesity • Paroxysmal nocturnal hemoglobinuria • Pregnancy/postpartum • Previous VTE • Smoking • Thrombophilia • Venous compression	• Cardiothoracic surgery • Central venous catheterization • Major surgery (general, gynecologic, orthopedic, peripheral vascular, or urologic) • Neurosurgery • Trauma	• Ensure early, aggressive mobilization • Provide mechanical prophylaxis • Consider chemoprophylaxis
ADL, activities of daily living; AKI, acute kidney injury; BUN, blood urea nitrogen; COPD, chronic obstructive pulmonary disease; CRF, chronic renal failure/insufficiency; GFR, glomerular filtration rate; GI, gastrointestinal; HbA1c, hemoglobin A1c; HF, heart failure; IBD, inflammatory bowel disease; JHSRCS, Johns Hopkins Surgical Risk Classification System; LMA, laryngeal mask airway; MAP, mean arterial pressure; METS, metabolic equivalents; SERMs, selective estrogen receptor modulators; URI, upper respiratory infection; VTE, venous thromboembolism.

TABLE 2
When should you order these ancillary tests?*

Albumin^† For at-risk populations⁹
BUN, creatinine, electrolytes For at-risk subpopulations²¹
Chest x-ray It depends. It is not used routinely for predicting risk but may be appropriate for patients with previous diagnosis of COPD or asthma.⁹
CBC, platelets Do not order routinely; check hemoglobin if procedure increases risk for bleeding.
Coagulation studies Do not order routinely.^35,36
Echocardiogram It is reasonable to order for patients with dyspnea of unknown origin, history of HF and worsening dyspnea, or other change in clinical status and may be considered for patients with previously documented cardiomyopathy.¹
EKG Vascular surgery: Order for patients with ≥1 clinical risk factors; it is also reasonable for patients with no clinical risk factors.¹Intermediate-risk procedure: Order for patients with CHD, PAD, or CVD and consider for patients with ≥1 clinical risk factors.¹
Exercise stress-testing Order for patients with active cardiac conditions; it is reasonable for vascular surgery candidates with ≥3 clinical risk factors and poor functional capacity and may be considered for patients undergoing vascular or intermediate-risk procedure who have 1-2 clinical risk factors and poor functional capacity.¹
Spirometry, pulmonary-function testing Do not order routinely for predicting risk, but may be appropriate for patients with previous diagnosis of COPD or asthma.⁹
Urinalysis Order routinely.²⁰
BUN, blood urea nitrogen; CBC, complete blood count; CHD, coronary heart disease; COPD, chronic obstructive pulmonary disease; CVD, cardiovascular disease; EKG, electrocardiography; HF, heart failure; PAD, peripheral artery disease.
*Most commonly recommended ancillary tests for which there are at least minimal data to suggest the validity of the opinion-based recommendation. Answers are opinion-based, not evidence-based. With the exception of albumin testing, the tests listed here are lacking in patient-oriented evidence of benefit from routine use.
† Routine testing of albumin levels is evidence-based.