PREOPERATIVE

ASSESMENT
 INTRODUCTION

• The stress of major surgery

• can lead to increased oxygen demand by up to 40%. Inflammatory changes
due to cytokine release, endocrine responses, hypercoagulability and
redistribution of fluid between compartments may last several
postoperative days. The purpose of careful preoperative planning is to
minimize the unwanted effects of these physiological changes.
• Primary care physician records and hospital notes are useful sources of
baseline information. MDT approach for optimisation of chronic conditions,
facilitates weight reduction and smoking cessation, and allows
coordination of prehabilitation and postoperative rehabilitation needs.
• The anaesthetist and surgeon must plan the safest anaesthetic technique
and operation for the patient.
• The risks of surgery and anesthesia and the effects of comorbid conditions should
be discussed so that the patient can make an informed decision. Patients should
be given advice on preoperative fasting times, adjustments to regular medication
and specific premedication at the preoperative visit.
• To enable the list to run smoothly on the day, key personnel involved in the list
(surgeon, anesthetist and senior theatre staff) should be involved in planning the
list order. The National Patient Safety Agency’s adaptation of the World Health
Organization’s checklist recommends a ‘team brief ’ before the start of each list,
which is also a valuable opportunity to share information with the theatre team
and improve the safety of anesthesia and surgery.
Preoperative plan for the best patient
outcomes
● Gather and record all relevant information
● Optimize patient condition
● Choose surgery that offers minimal risk and maximum benefit
● Informed consent of the patient
● Anticipate and plan for adverse events
● Adequate hydration, nutrition and exercise are advised
 Preoperative plan for the best patient outcomes

• History taking
• A thorough past medical history, surgical history and systemic enquiry
should be documented, including important negatives . The history of past
surgery and anesthetic events can reveal the problems one may face
during future procedures e.g. intraabdominal adhesions for planned
laparoscopic surgery, a difficult airway or suxamethonium apnoea. The use
of recreational drugs and alcohol consumption should be noted as they
are known to be associated with adverse outcomes. A full drug history and
list of allergies should be documented. Social history, ability to
communicate and mobility are important in planning admission, discharge
route and rehabilitation after surgery.
 Examination

• Patients should be treated with respect and dignity, receive a clear

explanation of the examination undertaken and be kept as comfortable
as possible. A chaperone should be present, especially for intimate
examinations. This should be part of a local guideline or policy.
• Examination is especially important in symptomatic individuals and at a
minimum should include cardiorespiratory examination and airway
assessment. Specifically, look for signs of heart failure, valvular heart
disease, peripheral vascular disease and respiratory disease
 Cardiovascular
• Valvular heart disease
• Ischaemic heart disease: angina, myocardial infarction, coronary stents
• Hypertension
• Heart failure
• Dysrhythmia
• Peripheral vascular disease
• Cardiac devices, i.e. permanent pacemaker
 Respiratory

• Chronic obstructive pulmonary disease

• Asthma
• Respiratory infections
• Obstructive sleep apnoea symptoms

Gastrointestinal
• Peptic ulcer disease and gastro-oesophageal refux
• Liver disease
 Genitourinary tract
• Urinary tract infection
• Renal dysfunction
• For females last menstrual period/pregnancy/breastfeeding status
 Neurological

• Epilepsy
• Cerebrovascular accidents and transient ischaemic attacks
• Parkinson’s disease
• Multiple sclerosis

• Psychiatric disorders

• Cognitive function
• Anxiety or depression
 Endocrine/metabolic

• Diabetes
• Thyroid dysfunction
• Phaeochromocytoma
• Porphyria
 Locomotor system

• Osteoarthritis
• Inflammatory arthropathy, i.e. rheumatoid arthritis
• Disorders of muscle, i.e. muscular dystrophy, myasthenia, myopathy
 Haematological

• Bleeding disorder
• Personal or family history of deep vein thrombosis and pulmonary embolism
• Objection to blood product transfusion
• Haemoglobinopathy, i.e. sickle cell disease

• Infection

• Human immunodefciency virus/hepatitis/tuberculosis

• Other, i.e. MRSA/COVID-19/drug-resistant organisms
 Previous surgery and anaesthesia

• Problems encountered, i.e. Difficult Airway Society Alert, suxamethonium apnoea

• Family history of problems with anaesthesia, i.e. malignant hyperpyrexia
 Examination
● General: positive findings, even if not related to the proposed procedure,
should be explored further
● Surgery related: type and site of surgery, with reference to imaging and
investigations
● Systemic: comorbidities and extent of limitation of each organ’s function
● Specific: for example, suitability for positioning during surgery or to plan
airway management
 Medical examination
• General
• Cardiovascular
• Respiratory
• Gastrointestinal, Neurological, Airway assessment
• Anaemia, jaundice, cyanosis, frailty, nutritional status, sources of infection (teeth, feet, leg
ulcers), height, weight and BMI
• Pulse rate and rhythm, blood pressure, heart sounds, bruits, jugular venous pressure,
peripheral oedema, exercise tolerance
• Respiratory rate and effort, chest expansion and percussion note, breath sounds, oxygen
saturation at rest and exertion, consider PEFR
• Abdominal masses, ascites, bowel sounds, hernia, genitalia
• Consciousness level, cognitive function, sensation, muscle power, tone and refaxes
• Mouth opening, neck extension, Mallampati score, thyromental distance, jaw protrusion,
scarring to mouth or neck, dentition
 Airway assessment
The difficulty encountered when performing airway manoeuvres, i.e. hand
ventilation, intubation and front of neck access, can be predicted to some
extent by simple examination. Failure to assess and plan airway management
can have fatal consequences.
The patient is assessed for:
• modified Mallampati class
• mouth opening >3 cm
• thyromental distance >6.5 cm;
• thyrosternal distance >12.5 cm;
• ability to protrude the jaw
• ability to extend the head at the atlantooccipital junction
 Airway assessment CONT

• When more than one of the above tests are abnormal, the chances of
experiencing difficulty in obtaining and securing the airway become greater.
Poor dentition, facial hair, upper airway tumours/scarring/infections,
obesity and neck size are also important factors that will affect the airway
management plan. Previous anaesthetic charts or alerts carried by
patients for a difficult airway are invaluable sources when assessing a
patient
 Airway assessment (Mallampati test as modifed by Samsoon and Young

• Grade 1 Fauces, pillars, soft palate and uvula seen

• Grade 2 Fauces, soft palate with some part of uvula seen
• Grade 3 Soft palate seen
• Grade 4 Hard palate only seen
 ASA Grade

Operative mortality by American Society of Anesthesiologists (ASA) grade.

• ASA grade Description 30-day mortality (%)

• I Healthy 0.1
• II Mild systemic disease, no functional limitation 0.7
• III Severe systemic disease, defnite functional limitation 3.5
• IV Severe systemic disease, constant threat to life 18.3
• V Moribund patient unlikely to survive 24 hours with or without operation 93.3
• E Emergency operation –
 GA fitness

• CBC
• FBS/RBS
• SERUM CREATININE
• URINE R/E
• CXR PA VIEW
• ECG
• HBsAg
• Disease Specific tests
 Investigations

• Full blood count (FBC). An FBC is needed for major operations, in the elderly and in those with
anaemia or pathology with ongoing blood loss and chronic disease
• Haemoglobin A1c (HbA1c) level. This should be measured in patients with diabetes who have not
had it measured in the last 3 months.
• Sickle cell test. Not routinely offered, but in cases of suspicion of a sickle crisis or a family history of
sickle cell disease a sickle cell test is needed.
• Urea and electrolytes (U&Es). U&Es are needed before all major operations, in patients over 65 years
of age, in patients with cardiovascular, renal or endocrine disease or if significant blood loss is
anticipated. They are also needed in those on medications that affect electrolyte levels, e.g. steroids,
diuretics, digoxin, nonsteroidal anti-inflammatory drugs, intravenous fluid or nutrition therapy, and in
those with endocrine problems.
 Investigations CONT
. Liver function tests. These are indicated in patients with jaundice, known or suspected hepatitis, cirrhosis,
malignancy, alcohol excess or poor nutritional status.
• Clotting/coagulation screen. This is needed if a patient has a history suggestive of a bleeding diathesis, liver
disease, eclampsia or cholestasis, is on antithrombotic or anticoagulant agents or has a family history of a
bleeding disorder. It should be noted that the effects of antiplatelet agents, lowmolecularweight heparins
(LMWHs) and newer agents affecting factor Xa cannot be measured by routine laboratory tests.
• Electrocardiogram (ECG). This is required for patients over 65 years of age or symptomatic patients with a
history of rheumatic fever, diabetes or cardiovascular, renal or cerebrovascular disease, with or without severe
respiratory problems. It will also depend on whether the surgery is minor/intermediate or major, as described in
NICE guidance.
• Chest radiograph. Not routinely offered unless there is concern on clinical examination.
• Echocardiogram (echo). Consider in those with heart murmurs who are symptomatic or in those with signs of
heart failure.
• Urine tests. Only consider microscopy and culture of midstream urine if infection would influence the decision to
operate.
• β-Human chorionic gonadotrophin (pregnancy test). Women of childbearing age should be asked sensitively
about their pregnancy status as this will affect the surgical plan and consent. Pregnant patients must be
consented for the risk to a fetus that surgery and anaesthetic pose, and obstetric advice sought. In addition, on
the day of surgery the woman should be consented for a urine/ serum pregnancy test
 Investigations CONT
Others:
• Venous bicarbonate. For patients who have screened as being at high risk for obstructive sleep
apnoea (OSA). Followed by formal sleep studies if significant OSA is a concern.
• Arterial blood gases. A low-cost tool that can give quick and vital information in acute or chronic
severe respiratory conditions, acid–base disturbances and conditions where there is a changing
milieu, e.g. immediately before kidney transplant.
• Blood group and cross-match if expected blood loss >500 mL.
• Methicillin-resistantStaphylococcus aureus (MRSA) swabs. Coronavirus 2019 (COVID-19)
polymerase chain reaction (PCR) swabs.
• Spirometry.
• Cardiopulmonary exercise testing to assess fitness for high-risk surgery.
• Specialist radiological views are sometimes required. If imaging is going to be needed during surgery,
this needs to be planned in advance.
 Common preoperative problems and management

• Specific medical problems encountered during preoperative assessment

should be corrected to the best possible level. Many patients with severe
disease will need to be referred to specialists; the referral letter should
contain all the details, including history, examination and investigation
results.
 Cardiovascular disease

• Perioperative cardiovascular complications are frequent. Patients who can climb

a flight of stairs without getting short of breath, having no chest pain or no needing
to stop are likely to tolerate a wide range of surgeries with an acceptable risk of
perioperative cardiovascular morbidity and mortality.
• However, at preoperative assessment it is important to identify those patients who
have a high perioperative risk of a major adverse cardiovascular event (MACE)
and to try to reduce this risk. Patients at high risk are those with ischaemic heart
disease (IHD), congestive cardiac failure, arrhythmias, severe peripheral vascular
disease, cerebrovascular disease or significant renal impairment, especially if they
are undergoing major intraabdominal or intrathoracic surgery.
 Ischaemic heart disease

• Patients with angina that is not well controlled should be investigated

further by a cardiologist.
• The indications for coronary revascularisation in patients awaiting surgery
are the same as at any other time. Pharmacological protection is indicated.
• Patients established on βblockers and statins should have their medication
continued perioperatively. Initiating statins preoperatively should be
considered if not already prescribed.
• Most long-term cardiac medications should be continued over the
perioperative period.
• Angiotensinconverting enzyme (ACE) inhibitors and receptor blockers are
often omitted 24 hours prior to surgery to prevent intraoperative hypotension,
and restarted the next day for most surgery.
• After a proven myocardial infarction , elective surgery should be
postponed for 3–6 months to reduce the risk of perioperative
reinfarction. Ischaemic changes can be seen on ECG even if the
patient is not symptomatic (silent ischaemia/silent MI). These
merit discussion with a cardiologist
 Hypertension

• Prior to elective surgery blood pressure should be controlled to <160/100

mmHg. If a new antihypertensive agent is introduced, a stabilisation
period of at least 2 weeks should be allowed.
 Heart failure

• Left ventricular failure is the end result of several conditions, including IHD,
hypertension, cardiomyopathies and valve dysfunction. Decompensated heart
failure puts the patient at risk of multiorgan failure. Those with ejection fractions
of less than 35%, and in whom the failure is undiagnosed or its severity
underestimated, are at highest risk. The patient’s functional capacity needs to be
assessed and surgery may have to be delayed for investigations such as an echo
and/or for optimisation of medical therapy. B type natriuretic peptide is a useful
marker and can be prognostic.
• Drugs used in chronic heart failure can have significant implications for
perioperative care, including intraoperative hypotension. Β blockers and probably
ACE inhibitors (unless renal perfusion is to be significantly affected) should be
continued. A left ventricular ejection fraction of less than 35% should be discussed
with a cardiologist and optimised. Cardiac resynchronisation therapy devices may
be considered, depending on the QRS duration.
 Drug-eluting coronary stents (DES)

• Primary percutaneous intervention is the treatment of choice for acute

coronary syndromes, and many patients receive stents and are on dual
antiplatelet therapy for 12 months. If surgery is absolutely necessary within
the period of dual antiplatelet therapy, the management strategy should be
decided jointly by the surgeon, cardiologist, anaesthetist and patient, as it
is essential to consider the balance of risk of continuing antiplatelet
agents (with the risk of increased bleeding) and stopping them (with the
risk of stent thrombosis).
 Dysrhythmias

• In patients with atrial fibrillation (AF), β blockers, digoxin or calcium

channel blockers should be continued in order to control rate.
• New AF or atrial futter should be investigated and treated. These patients
should be considered for cardioversion as restoring sinus rhythm can
improve cardiac output by 15% .
• Patients with an abnormal rhythm on ECG, for example tachycardia/
bradycardia or heart block, should also be discussed with a cardiologist .
Symptomatic heart blocks and asymptomatic second(Mobitz II) and third-
degree heart blocks, if discovered at the preoperative assessment clinic,
will need cardiology consultation and potentially temporary or permanent
pacemaker insertion.
 Dysrhythmias Cont

• Warfarin in patients with AF should be stopped 5 days preoperatively to

achieve an international normalised ratio (INR) of 1.5 or less, which is safe
for most surgery. The newer anticoagulants such as dabigatran (direct
thrombin inhibitor) or rivaroxaban, apixaban and edoxaban (direct factor
Xa inhibitors) do not have antagonists and must be stopped preoperatively,
generally for 2–3 days in patients with normal renal function and longer
when renal function is impaired. Alternative anticoagulation is not required
in the perioperative period unless the risk of stroke is high (assessed using
the CHA2DS2VASc [congestive heart failure, hypertension, age ≥75 years,
diabetes mellitus, stroke or transient ischemic attack, vascular disease,
age 65–74 years, sex category] score). Decisions on bridging therapy
should balance the risks of stroke and bleeding.
 Implanted pacemakers and cardiac defbrillators

• Checks and appropriate reprogramming should be done preoperatively by

specialists and advice followed. Monopolar diathermy activity during
surgery may be sensed by the pacemaker as ventricular fibrillation or a
paced beat. Therefore, cardioversion and over pace modes must be
turned of (and switched back on after surgery) or converted to ‘ventricle
paced, not sensed with no response to sensing’ (VOO) mode. Bipolar
diathermy should be made available at surgery.
 Valvular heart disease
• While anaesthetic management is altered to achieve haemodynamic stability in
moderate valvular diseases, patients with severe aortic and mitral stenosis may
benefit from valvuloplasty before elective noncardiac surgery.
• Appropriate referral to an anaesthetist and cardiologist should be made. An echo is
required in symptomatic patients with a new murmur.
• Patients with known significant valve pathology may benefit from a recent echo.
• In patients with mechanical heart valves, warfarin needs to be stopped preoperatively
and bridging anticoagulation given to prevent valve thrombosis. Bridging options
include unfractionated heparin infusions or LMWHs and should be done under
guidance agreed with haematology. Bridging therapy should continue postoperatively
until the patient is reestablished on warfarin with a therapeutic INR but must be
balanced with the postoperative bleeding risk.
• Thrombin inhibitors and factor Xa inhibitors are not licensed and should
not be used in patients with mechanical valves.
 Cerebral vascular disease

• Patients who have suffered a cerebrovascular accident have been shown

to have a higher rate of MACE postoperatively. This is highest in the first 3
months after a stroke. The urgency of surgery needs to be discussed with
the surgeon, anaesthetist and a stroke physician. Ideally elective surgery is
postponed until MACE risks stabilise after 9 months. The bleeding versus
thrombosis risk of continuing dual antiplatelet therapy needs to be
considered .
 Respiratory disease
Postoperative respiratory complications, such as pneumonia, are a major cause of
morbidity and mortality, especially after major abdominal and thoracic surgery. A
patient’s current respiratory status should be compared with their ‘normal state’.
Patients with severe disease are at risk of pneumonia and respiratory failure in the
postoperative period.
Severe disease would include patients with a forced expiratory volume in the first
second (FEV1) of less than 30% of predicted value, dependence on oral steroid
treatment, home ventilation or oxygen therapy or a PaCO2 level of greater than 6
kPa. Patients should continue to use their regular inhalers until the start of
anaesthesia. Brittle asthmatics may also need extra steroid cover. Encourage the
patients to be compliant with the medications and stop smoking.
Information should be provided to indicate perioperative risks associated with
smoking. Stopping smoking reduces carbon monoxide levels and offers the patient
a better ability to clear sputum. Evidence suggests that preoperative inspiratory
muscle training significantly improves respiratory (muscle) function in the early
postoperative period, reducing the risk of pulmonary complications.
 Respiratory disease cont

Regional anaesthetic techniques and less invasive surgical options should

be considered in severe cases. Elective surgery should be postponed until
acute exacerbations are treated.
• The patient should be referred to a respiratory physician if:
• there is a severe disease or significant deterioration;
• major surgery is planned in a patient with significant respiratory
comorbidities;
• right heart failure is present – dyspnoea, fatigue, tricuspid regurgitation,
hepatomegaly and oedematous feet;
• the patient is young and has severe respiratory problems (may indicate a
rare condition).
 Gastrointestinal disease

Regurgitation risk
• Patients undergoing general anaesthesia or sedation have a risk of regurgitation
of stomach contents and aspiration pneumonia. To reduce this risk patients
should fast preoperatively. This should be clearly explained to the patient: 6 hours
for solids or nonclear fluids (e.g. milk), 2 hours for clear fluids and 4 hours for
infants consuming breast milk. Prolonged fasting is detrimental to the patient so
should not be encouraged. Patients with hiatus hernia, obesity, pregnancy or
diabetes are at higher risk of pulmonary aspiration, even if they have been fasted
appropriately before elective surgery. Clear antacids, H2receptor blockers, e.g.
ranitidine, or proton pump inhibitors, e.g. omeprazole, may be given at an
appropriate time in the preoperative period to reduce stomach acidity .
 Liver disease
• In patients with liver disease, the cause of the disease needs to be known,
as well as any evidence of clotting problems, renal involvement and
encephalopathy. Elective surgery should be postponed until any acute
episode has settled, e.g. cholangitis. The presence of ascites,
oesophageal varices, hypoalbuminaemia or sodium and water retention
should be noted, as all can infuence the choice and outcome of
anaesthesia and surgery. Patients with cirrhosis undergoing major surgery
have a very high mortality; the Model for Endstage Liver Disease (MELD)
can be used to predict mortality of cirrhotic patients undergoing
nontransplant surgery. If alcohol addiction is the aetiology then reduction
of alcohol intake should be encouraged but abstinence must be medically
supervised to prevent delirium tremens.
 Genitourinary disease
Renal failure
• Underlying conditions leading to chronic renal failure such as diabetes
mellitus, hypertension and IHD should be stabilised before elective surgery.
Appropriate measures should be taken to treat acidosis, hypocalcaemia
and hyperkalaemia of greater than 6 mmol/L. Arrangements should be
made to continue peritoneal dialysis or haemodialysis until a few hours
before surgery. After the fnal dialysis before surgery, a blood sample
should be sent for FBC and U&Es.
• Patients with chronic renal failure often have chronic anaemia that is well
tolerated; therefore, preoperative blood transfusion is often not necessary.
Optimisation of the haemoglobin is best guided by the renal team.
 Urinary tract infection
• Uncomplicated urinary tract infections are common in women, while
outflow uropathy with chronically infected urine is common in men. These
infections should be treated before embarking on elective surgery where
infection carries dire consequences, e.g. joint replacement. For emergency
procedures, antibiotics should be started and care taken to ensure that the
patient maintains a good urine output before, during and after surgery.
 Endocrine and metabolic disorders
Malnutrition

• Body mass index (BMI) is weight in kilograms divided by height in meters

squared. A BMI of less than 18.5 indicates nutritional impairment and a
BMI below 15 is associated with significant hospital mortality. Nutritional
support for a minimum of 2 weeks before surgery is required to have any
impact on subsequent morbidity. If a patient is unlikely to be able to eat for
a significant period postoperatively this can be anticipated and alternative
nutritional support must be planned.
 Obesity
• Morbid obesity can be defend as BMI of more than 35 (other definitions exist) and
is associated with an increased risk of postoperative complications. Patients
should be made aware of the risks involved and advised on healthy eating and
taking regular exercise. If possible, surgery should be delayed until the patient is
more active and has lost weight. If this fails, prophylactic measures need to be
taken, such as preventative measures for acid aspiration and deep vein
thrombosis (DVT). OSA that is unrecognised has been shown to be associated
with a higher incidence of MACE in comorbid patient groups. Identification of
those at higher risk by using a clinical scoring system, such as the perioperative
sleep apnoea prediction (PSAP) score, can rationalise referral for formal sleep
apnoea studies. Urgency of surgery may preclude full investigation and treatment
preoperatively. Patients with severe OSA require 6 weeks of nocturnal continuous
positive airway pressure (CPAP) use preoperatively to reduce their risks.
Associated risks need to be explained prior to the surgery and an appropriate
anaesthetic technique planned with postoperative monitoring.
 Diabetes mellitus

• Diabetes and associated cardiovascular and renal complications should be

controlled to as near a normal level as possible before embarking on elective
surgery. Any history of hyperand hypoglycaemic episodes and hospital admissions
should be noted. For elective surgery, an HbA1c of <69 mmol/mol is
recommended. Lipidlowering medication should be started in patients who are in
a highrisk group for cardiovascular complications of diabetes. Patients with
diabetes should be first on the operating list and their antidiabetic medication
adjusted as per local or national guidance, as they will miss a meal preoperatively.
Although tight control of blood sugar is not needed, the patient’s blood sugar levels
should be checked hourly. Variable rate intravenous insulin infusion (VRIII) should
be started for patients with diabetes on insulin undergoing major surgery or if
blood sugar is difficult to control for other reasons.
 Adrenocortical suppression
• Patients receiving oral adrenocortical steroids should be asked about the
dose and duration of the medication to determine the need for
supplementation with extra doses of steroids perioperatively so as to
avoid an Addisonian crisis. A patient taking >5 mg prednisolone equivalent
within a month of surgery will require supplementation at induction and
postoperatively.
• Neuroendocrine tumours, including phaeochromocytoma, carcinoid,
gastrinoma, VIPomas and insulinoma, have specific treatments that must
be started preoperatively in liaison with specialist endocrinology
physicians.
 Haematological disorders
Anaemia and blood transfusion
• Patients found to be newly anaemic (haemoglobin <130 g/L), with an expected
operative blood loss of >500 mL, should be investigated for the cause of their
anaemia. Any vitamin or iron defciency should be corrected before proceeding for
elective surgery. Chronic anaemia is well tolerated in the perioperative period where
<500 mL blood loss is expected, but where possible should be corrected.
Preoperative transfusion may be considered rarely for elective patients when guided
by a haematologist. Local policy should agree which procedures require a
preoperative ‘group and save’ or crossmatched blood sample. Some patients may
refuse blood transfusion, for example a Jehovah’s Witness. In such a case, during the
consent process discussion should include which blood product and/or device
system (e.g. cell salvage, reinfusion from drains) is acceptable. The discussion
should extend to other areas, for example whether refusal of transfusion would apply
in lifethreatening situations. As in all consent processes, the discussion and
outcome should be clearly documented.
 Thrombophilia
• Factor V Leiden and deficiencies in antithrombin III and proteins C and S
increase the patient’s thrombosis risk. The patient will need special
discussion with a haematologist to tailor their venous thromboembolism
prophylaxis. For all other patients a DVT risk assessment should be made
preoperatively and precautions planned as per local or national guidance.
Risk factors are includedTable
in 21.4 . The progesteroneonly
contraceptive pill should be continued; however, the risks of continuing the
combined pill (slight increased risk of significant thrombosis) should be
weighed against the risks of an unplanned pregnancy. Consider stopping
oestrogencontaining oral contraceptives or hormone replacement therapy
4 weeks before surgery (NICE guidance; Further
see reading ).
 Bleeding disorders
• Bleeding disorders such as haemophilia, von Willebrand disease or
thrombocytopenia are best discussed with haematology preoperatively.
 Neurological and psychiatric disorders

• Anticonvulsants and antiParkinson’s medication must be continued

perioperatively to help early mobilisation of the patient, and patients
should be planned early on a theatre list to reduce starvation times.
Parenteral medication plans can be set in place preoperatively if there is
potential for a prolonged ‘nil by mouth’ period postoperatively.
• Lithium should be stopped 24 hours prior to major surgery but can be
continued for minor surgery with careful fluid management and U&Es
monitoring. The anaesthetist should be informed if patients are on
psychiatric medications, such as tricyclic antidepressants or monoamine
oxidase inhibitors (MAOIs), as these may interact with anaesthetic drugs.
Casebycase decisions with a psychiatrist must be undertaken as stopping
irreversible MAOIs safely may take many weeks of planning under
psychiatric supervision.
 Musculoskeletal disorders
• Muscular disorders have serious implications and require a tailored anaesthetic approach. They
include muscular dystrophies, myotonic dystrophy and myasthenia gravis and a personal or family
history of malignant hyperpyrexia.
• Rheumatoid arthritis can lead to an unstable cervical spine with the possibility of spinal cord injury
during intubation. Therefore, fexion and extension lateral cervical spine radiographs should be
obtained in symptomatic patientsFigures
( 21.7 and 21.8 ). Assessment of the severity of renal,
cardiac, valvular and pericardial involvement as well as restrictive lung disease should be carried out.
Rheumatologists will advise on steroids and diseasemodifying drugs so as to balance
immunosuppression (chance of infections) against the need to stabilise the disease perioperatively
(stopping diseasemodifying drugs can lead to fare up of the disease). In patients with ankylosing
spondylitis, in addition to the problems discussed above, techniques of spinal or epidural
anaesthesia are often challenging. Patients with systemic lupus erythematosus may exhibit a
hypercoagulable state along with airway difficulties.
 PHYSICAL FITNESS
• Functional physical ftness can be judged by the ability to tolerate metabolic
equivalent tasks (METs) Table
( 21.5 ). One MET is equivalent to the oxygen
consumption of an adult at rest (~3.5 mL/kg/min). Diferent tasks are assigned a
number of METs. If the patient is able to perform >4 METs (e.g. climbing at least
one fight of stairs) they are accepted to proceed for lowrisk surgery in the USA and
Europe. However this depends on a subjective assessment of the ability of a
patient and may be overestimated by them. The Duke Activity Status Index (DASI)
is a less subjective patient questionnaire. An estimate of the patient’s peak oxygen
consumption (VO2 peak can be calculated from their point score. Although it
correlates with cardiopulmonary exercise testing (CPET), some patients who
score poorly on DASI go on to score well on CPET. An objective measure of ftness
is required for highrisk surgery.
 Cardiopulmonary exercise testing

• CPET is the gold standard measurement of a patient’s ftness. The oxygen consumption (VO2) and carbon
dioxide production (VCO2) of the patient are measured while they undergo a 10minute period of
incrementally demanding exercise (usually on a cycle ergometer) up to their maximally tolerated level
Figure
( 21.9 ).
• CPET is based on the principle that, when a subject’s delivery of O2 to active tissues becomes inadequate,
anaerobic metabolism begins; lactate is buffered by bicarbonate and the resulting CO2 increases out of
proportion to the escalation in physical difficulty and O2 consumption. The ‘anaerobic threshold’ (AT) is
the VO2 in mL/kg/min at which this occurs. Peak oxygen consumption is also measured. This is the end
product of a subject’s combined respiratory, cardiac, vascular and musculoskeletal fitness, and subjects
with either an AT below 11 mL/kg/min or a VO2 peak below 15 mL/kg/min are at higher risk of morbidity
and mortality after major surgery. Patients who are found to be unfit can be enrolled in prehabilitation.
This involves supervised exercise over 4–6 weeks with the aim of improving the patient’s AT and reducing
their risk profile. Where CPET is not available, the lowcost incremental shuttle walk test (ISWT) is an
attractive option. It depends on the patient’s ability to walk at increasing speed over a fat surface.
Patients who fail to achieve 350 metres on the ISWT have been shown to be at higher risk for
oesophageal surgery. It correlates well with VO2 peak but does not identify all lowrisk patients as it is
subject to patient motivation and is afected by sex, age and height.
 Cardiopulmonary exercise testing cont

• CPET is based on the principle that, when a subject’s delivery of O2 to active tissues
becomes inadequate, anaerobic metabolism begins; lactate is bufered by bicarbonate
and the resulting CO2 increases out of proportion to the escalation in physical
difculty and O2 consumption. The ‘anaerobic threshold’ (AT) is the VO2 in mL/kg/min
at which this occurs. Peak oxygen consumption is also measured. This is the
endproduct of a subject’s combined respiratory, cardiac, vascular and
musculoskeletal ftness, and subjects with either an AT below 11 mL/kg/min or a VO2
peak below 15 mL/kg/min are at higher risk of morbidity and mortality after major
surgery. Patients who are found to be unft can be enrolled in prehabilitation. This
involves supervised exercise over 4–6 weeks with the aim of improving the patient’s
AT and reducing their risk profle. Where CPET is not available, the lowcost
incremental shuttle walk test (ISWT) is an attractive option. It depends on the
patient’s ability to walk at increasing speed over a fat surface. Patients who fail to
achieve 350 metres on the ISWT have been shown to be at higher risk for
oesophageal surgery. It correlates well with VO2 peak but does not identify all lowrisk
patients as it is subject to patient motivation and is afected by sex, age and height.
 CONSENT

• Consent is a key part of preoperative care. The process of consent has

evolved over the years and, in the UK, is determined by relevant Acts of
Parliament, legal judgement and the development of specifc guidance.
Chapter 14 .
Consent is considered in detail in
 ASSESSMENT OF RISK
Despite more comorbid patients presenting for surgery, the perioperative mortality has decreased
signifcantly over the last half century, especially in resourcerich countries. In a published systematic
review inThe Lancet by Bainbridge et al. (2012), perioperative mortality has declined from 10 603 per
million (95% confdence interval [CI] 10 423–10 784) in the 1970s to 1176 per million (95%CI
1148–1205) in the 1990s to 2000s P ( < 0.0001). However, there remains a subgroup of patients who
are at higher risk of morbidity and mortality after surgery. Patients who have a predicted mortality ≥5%
should be considered as ‘high risk’. It is estimated that, although the highrisk group accounts for less
than 15% of all surgical procedures, they contribute to more than 80% of all perioperative deaths in UK.
What causes these patients to be at a high risk of death and complications after surgery? After surgery
tissue destruction, blood loss, fuid shifts and changes in temperature, pain and anxiety result in
increased demands for oxygen delivery to the tissues. This demand increases from an average of 110
mL/min/m at rest to 170 mL/min/m in the postoperative period. Most patients meet this increase in
2 2

demand by increasing their cardiac output and tissue oxygen extraction. Patients who are unable to
meet these demands, as a result of a limited cardiorespiratory reserve, are at a risk of oxygen debt.
Occult hypovolaemia resulting from fuid shift or blood loss can further impair oxygen delivery.
Splanchnic vasoconstriction to compensate for this may result in gut ischaemia. Those with coronary
or cerebrovascular disease are also at a higher risk of myocardial ischaemia or stroke.
 Factors contributing to risk
• Risk is a complex interaction of multiple factors that can be classifed into patient and surgical factors.
Patient factors are listed inTable 21.6 . The elderly, although not independently at higher risk, not
only have more cardiac, pulmonary and renal disease but also require surgery four times as often as
the rest of the population. Around 10% of the population over 65 are frail, with increasing incidence
associated with age. Multiple body systems lose their inbuilt reserves in the elderly. The type of
surgery contributes independently and is listedTable
in 21.7 . This risk increases if the surgery is
performed as an emergency. Often, the underlying condition requiring surgery itself may be
associated with an increased risk of complications. For example, a patient with severe peripheral
vascular disease resulting from heavy smoking may need a femoral–popliteal bypass graft and can
be expected also to have signifcant COPD and IHD. Moreover, when mortality by type of surgery is
adjusted for patient risk factors, the apparent hierarchy of surgical risk may change. The average
mortality risk for an individual patient undergoing thoracic surgery, for example, is likely to be higher
than the average risk for that same patient undergoing vascular surgery. Complications associated
with the latter are nevertheless more frequent because vascular patients have greater medical risk
factors.
 Risk prediction
• The key to managing patients efectively is the identifcation and accurate quantifcation of
the risk, and subsequent measures taken to minimise it. Realistic estimates of risk are
the cornerstone of informed patient consent and shared decision making. The patient
and the surgeon may choose a less extensive or even a nonsurgical option when the risks
of the defnitive procedure are deemed to be too high or unacceptable. The Royal College
of Surgeons of England has recommended that patients who are predicted to have >5%
mortality risk should have active consultant input in all stages of their management.
Surgical procedures in those with predicted mortality of >10% should be conducted under
the direct supervision of a consultant surgeon or anaesthetist, unless the consultants are
satisfed with the seniority and competence of the staf managing these patients.
Moreover, those with a mortality >10% should be managed in the critical care facility
postoperatively. The identifcation of patients who will beneft the most from these
interventions is important, not only for the improvement of outcomes but also for the
efective allocation of resources. A number of scoring systems have been developed over
the years with the aim of identifying highrisk patients.
 American Society of Anesthesiologists system
• The ASA scoring system is widely used. Although not designed to be used as a risk prediction score,
it has a quantitative association with the predicted percentage of postoperative mortality Table
(
21.10 ). However, it does not account for the patient’s age or the nature of the surgery and the term
‘systemic disease’ in ASA grading introduces an element of ‘subjectivity’. Examples of each physical
status added in 2015 aim to reduce this.
 The POSSUM score
• The POSSUM (Physiologic and Operative Severity Score for the enUmeration of Mortality and
Morbidity) and its modifcations (PPOSSUM, CRPOSSUM) are used to predict allcause mortality in
postoperative critical care patients as well as noncardiac morbidity.
 Lee’s Revised Cardiac Risk index

• Lee’s Revised Cardiac Risk index (RCRI) uses objective indices

based on weighted scores pertaining to surgery and comorbidity.
This stratifes cardiac risk but is not designed to predict
mortality
 ACS NSQIP score
The American College of Surgeons (ACS) National Surgical
Quality Improvement Program (NSQIP) surgical risk score
estimates the chance of a complication or death after surgery for
more than a thousand diferent surgical procedures. It compares
the patient’s risk with an average person’s risk. It is a Webbased
tool done preoperatively. The risk is calculated based on surgical
procedure and 19 patientspecifc preoperative risk factors.
 Choosing the right operation for the high-risk patient

• There are situations in which the selection of one surgical technique over another
may be signifcantly infuenced by patient risk factors. Some procedures are not
primarily high risk but may become so in unsuitable patients. Laparoscopic surgery,
for example, has come of age as a preferred technique for patients predisposed to
postoperative respiratory complications, but its efect on cardiac physiology means
that the same may not apply to patients at risk of cardiac complications. The
expanding demand and indications for minimal access surgery are now pushing
the boundaries of intraoperative physiological tolerance. Robotic prostatectomy
and some laparoscopic colorectal procedures require a pneumoperitoneum with
steep Trendelenburg (head down) positioning for several hoursFigure
( 21.10 ).
This can be associated with adverse cardiovascular and neurological
complications, such as myocardial ischaemia and increased intracranial pressure
in the highrisk group. This risk may be minimised by attention to patient selection.
 Role of critical care and outreach services
• Reports from the National Confdential Enquiry into Patient Outcome and
Death (NCEPOD) show that the majority of postoperative deaths in the UK
occur more than 5 days after surgery. Admission to a critical care unit
allows for early treatment of complications and a level of care that is
difcult to deliver in the ward environment during this crucial period.
Common complications include myocardial ischaemia, cardiac,
respiratory or renal failure and sepsis. Perioperative MI is associated with
a high mortality (15–25%). Critical care uses invasive cardiac monitoring
and vasoactive drugs to help provide cardiac stability postoperatively to
minimise ischaemia and guide fuid management to prevent cardiac failure.
 Role of critical care and outreach services cont
• Postoperatively, 1.5% of patients develop lower respiratory tract infection after surgery, with a
30day mortality of >20%. Respiratory failure, which is defned as PaO2 <8 kPa in air, PaO2/
FiO2 (the ratio of arterial oxygen partial pressure to the fraction of inspired oxygen) <40 kPa
or the inability to extubate a patient 48 hours after surgery, is by far the most signifcant of
these and is associated with a mortality of 27–40%. Elective noninvasive ventilation, chest
physiotherapy and incentive spirometry should be considered for patients at increased risk of
respiratory complications. These are commonly delivered on the critical care unit.The highrisk
surgical population accounts for 80% of postoperative deaths, but only about 15–30% of
highrisk surgical patients are admitted to a critical care unit at any time following surgery.
Work by the National Emergency Laparotomy Audit in the UK is seeking to standardise
treatment of this highrisk group with many recommendations, including admission to critical
care where predicted mortality is >5%. In the last decade, the role of critical care has been
expanded to the concept of ‘critical care without walls’. The intensive care outreach services
(ICORS) grew from a recognition that there were many patients in hospital who are at risk of
being critically ill and that early identifcation of these patients using ‘early warning scores’
could allow for early intervention. The outreach team functions to bridge the gap between the
critical care unit and ward.
 ARRANGING AN ELECTIVE THEATRE LIST
• The date, place and time of operation should be matched with the
availability of appropriately skilled personnel. Appropriate equipment and
instruments should be made available. The operating list should be
distributed as early as possible to all staff who are involved in making the
list run smoothlyTable
( 21.12 ). If this is done electronically, familiarity with
the computer system is required. A critical care bed should be
prearranged for high-risk cases. Elective list order should priorities
patients who are vulnerable to long starvation times, e.g. children and
patients with diabetes.
 ARRANGING AN ELECTIVE THEATRE LIST cont

• For a prompt theatre start, planning a straightforward case first

can utilise time waiting for preprocedural imaging on the
second case, e.g. breast wire insertion, or confirmation of a
postoperative critical care bed for a high-risk case. List planning
using a surgeon’s average operation times for a procedure rather
than generic estimates leads to better list utilisation. Staggering
admission times can improve patient satisfaction but reduces
flexibility for ‘on the day’ changes to list order.
 Perioperative teams.

• Ward, theatre and specialist nursing staff

• Anaesthetic and surgical teams
• Radiology and pathology involvement
• Rehabilitation and social care workers
• Administration and scheduling team
• Specifc personnel in individual cases, e.g. cardiac devices team
 PREOPERATIVE ASSESSMENT FOR EMERGENCY SURGERY

• In emergency surgery the principles of preoperative assessment

should be the same as in elective surgery, except that the
opportunity to optimise the condition of the patient is limited by time
constraints. The urgency of surgery should be graded, e.g. by using
the NCEPOD classifcation of intervention, and emergency theatre
cases should be prioritised accordingly, i.e. immediate (within
minutes), urgent (within hours), expedited (within days) or elective
(timing to suit patient, hospital and staf).
PREOPERATIVE ASSESSMENT FOR EMERGENCY SURGERY cont

• Medical assessment and treatments should be started even if

there is no time to complete them before the start of a
timecritical surgical procedure. Some risks may be reduced but
some may persist; whenever possible, these need to be
discussed with the patient during the consent process.
Optimisation before urgent surgery can be more efective in a
critical care environment and patients may need to be admitted
to critical care preoperatively. The likelihood of a highrisk
emergency patient requiring postoperative critical care should
be identifed and discussed with the duty critical care physician.
 Summary box 21.3 Preoperative assessment for emergency surgery
• ● Start. Similar principles to that for elective surgery
• ● Constraints. Time, facilities available
• ● Consent. May not be possible in life-saving emergencies
• ● Organisational efforts. For example, local/national algorithms for the treatment of patients with
multiple injuries.