Pre-operative assessment
Please click here for Preoperative Cardiac Risk Assessment
For a printable checklist for pre-operative cardiac work up click here

# Overview
The goal of the preoperative clearance (Preoperative medical assessment) is to assess the patient's general medical condition in order to identify any unrecognized co-morbid diseases and optimize the patient's state for the procedure. The preoperative medical assessment helps the doctors to decide if the patient is suitable for the proposed surgery according to the patient's risk category, also it helps them to identify the factors that may reduce the patient's risk for complications and provide the best possible recommendations for the post-operative care.
Preoperative clearance usually starts by identifying the type of surgery to be performed and the risk category of the patient who needs this surgery.

# Perioperative risk of death
Patients can be divided into different risk categories based on the basis of their preoperative medical assessment. This helps the doctors to decide if the patient is suitable for the proposed surgery or procedure, and identify the factors that may reduce the patient risk. There are many factors that may influence the risk of perioperative complications, including death.
- Anesthesia
- Type of surgery
- Patient age
- Emergency procedures
- Pulmonary factors
- Cigarete smoking.
- Respiratory diseases.
- Abnormal chest x-ray or phisical examination findings.
- Thoracic or upper abdominal surgery.
- Morbid obesity.
- Age over 60.
- Cardiac factors
- History of prosthetic valves.
- History of rheumatic fever.
- Congestive heart failure.
- Arrhithmia.

# Preoperative patient questionnaire
In general, the overall risk of surgery is extremely low in healthy individuals.
History
- The patient should be asked about his age. Some studies found a small increased risk of surgery with advanced age of the patient. The mortality rate for most surgical procedures increases linearly with age due to increasing numbers of comorbidities with advancing age.
- The patient should be asked if he had a history of:
- Heart diseases,irregular heart beat, murmurs or rheumatic fever as a child.
- Pulmonary diseases, such as asthma, bronchitis, or emphysema.
- Chest pain, angina, or chest tightness.
- Hypertension or hypotension.
- Shortness of breath, cough.
- Liver diseases, jaundice or hepatitis.
- Gastrointestinal problems or indigestion.
- Diabetes.
- Thyroid problems.
- Kidney problems.
- Weakness or numbness in the extremities.
- Seizures or blackouts.
- Bleeding disorders.
- Blood clotting abnormality.
- Arthritis or joint pain.
- The patient should be asked about:
- Any allergies for food or medication.
- A list of any medications he is currently taking, including over-the-counter medications and steroidal compounds. Nonsteroidal anti-inflammatory drugs are associated with :an increased risk of perioperative bleeding.
- Any other medical conditions in the past.
- Any previous surgeries or anesthesia.
- pregnancy state.
- Any problems with a previous surgery due to anesthesia.
- The patient should be asked when did he last eat or drink on the day of surgery.
- The patient should be asked about his height and weight. Studies showed that obesity is not a risk factor for most adverse postoperative outcomes, with the exception of :deep venous thrombosis and pulmonary embolism. However, some cardiac surgery studies have shown higher complication rates for obese patients, such as prolonged hospital stay, wound infections and prolonged mechanical ventilation  .
- The patient should be asked about his exercise capacity, patients with unlimited exercise tolerance generally have a low risk of postoperative complications. Those patients :can walk two blocks on level ground without symptoms,
- The patient should be asked if he smokes cigarettes, how many packs per day and for how many years.
- The patient should be asked if he drinks alcohol. There is increased risk for postoperative complications in patients who misuse alcohol on a regular basis.
- The patient should be asked about his family history.

# Preoperative laboratory testing
The American society of anesthesiologists recommends against routine preoperative laboratory testing in the absence of clinical indications . In specific circumstances, selective testing may be appropriate, such as in patients with underlying diseases or risk factors that would increase their risk for surgical complications. Also in specific high risk surgical procedures, these tests should be done. If there is no significant change in the clinical condition of the patient, it may be safe to use test results that were performed within the past four months.
These tests include:
1. Complete blood count (CBC): Anemia maybe presents in asymptomatic patients and it is common following major surgery. Postoperative mortality maybe predicted by the preoperative hemoglobin level . 
CBC test should be done for:
- Patients 65 years of age or older.
- Patients who are undergoing major surgery.
- Young patients who undergoing major surgery with the expectation to result in significant blood loss.
- Patients with a history that suggests anemia.
2. Renal function test (RFT): Serum creatinine concentration should be ordered for patients over the age of 50 undergoing intermediate or high risk surgeries, also it should be ordered if hypotension is likely, or when nephrotoxic medications will be used. Mild to moderate renal impairment is usually asymptomatic. Dosage adjustment of some medications may be needed if the patient has renal insufficiency.
3. Electrolytes: It is not recommended to be done routinely if the patient does not have a history of electrolytes abnormality.
4. Blood glucose: Diabetes increases the operative risk in patients undergoing vascular surgery or coronary artery bypass grafting . Routine measurement of blood glucose is not recommended for healthy patients before the surgery, since some studies showed that unexpected abnormal blood glucose results do not often influence perioperative management .
5. Liver function tests (LFT): It is not recommended to do this test routinely unless the patient has a history of liver disease .
6. Hemostasis tests: It is not recommended to do prothrombin time (PT) or Partial thromboplastin time (PTT) blood tests routinely unless the patient has bleeding disorder or an unusual bleeding tendency . Some doctors have suggested to test all patients who undergoing intermediate to high risk surgeries. This avoids the chance that clinicians may forget to ask the patients about their bleeding history. The bleeding time is not useful in assessing the risk of perioperative hemorrhage .
7. Urinalysis: It is usually done to detect any urinary tract infection which has the potential to cause wound infection after the surgery , especially with prosthetic surgery. If the test is positive, the patient should be treated with antibiotics and proceed with surgery without delay. Some studies showed that there is no reduction in the risk of postoperative wound infection if the patient treated with antibiotics before the surgery, and so, it is not indicated to test for Urinary tract infection before the surgery for every patient .
8. Pregnancy testing: Pregnant women may need specific perioperative management, this includes specific anesthetic teqniques. An elective surgery may be cancelled or postponed in pregnant women. The American society of anesthesiologists recommends that clinicians consider pregnancy testing for all woman of childbearing age . Many institutions require pregnancy testing for all reproductive age women before surgery.
9. Electrocardiogram (EKG): This should be done to detect any recent myocardial infarction (MI) which known to be associated with increased surgical morbidity and mortality , also it may be important as a baseline to be compared with the one postoperatively. In general, EKG alone may be a poor indicator of postoperative cardiac complications. 
The 2007 American college of cardiology/American heart association (ACC/AHA) Guidelines on perioperative cardiovascular evaluation states that ECG is not useful in asymptomatic patients undergoing low risk procedures . Also, the European Society of Cardiology 2009 preoperative guidelines do not recommend ECG in patients without risk factors .
According to the 2007 ACC/AHA guidelines the 12-lead ECG are recommended for the following patients:
- Patients who are scheduled to undergo vascular surgery and have at least one of the following clinical risk factors:
- Ischemic heart disease.
- Compensated or prior heart failure.
- Cerebrovascular disease.
- Diabetes.
- Renal insufficiency.
- Patients who are scheduled to undergo intermediate-risk surgery with known cardiovascular disease, peripheral artery disease, or cerebrovascular disease.It is less strongly recommended to perform an ECG for patients scheduled to undergo intermediate-risk surgery with at least one clinical risk factor.
10. Chest radiograph (Chest x-ray): Its not recommended to do this test routinely before the operations in healthy patients, many studies showed that an abnormal chest x-ray findings may occur frequently, especially in elderly persons . According to the American College of Physicians (ACP), if there is a suspicion of cardiopulmonary disease from the patient's history or physical examination, then this test should be done, also in those older than 50 years of age who are undergoing abdominal aortic aneurysm surgery or upper abdominal/thoracic surgery .
The American heart association (AHA) recommends preoperative chest x-ray for patients with morbid obesity (BMI 40 kg/m2).
11. Pulmonary function test (PFT): This test only recommended for patients who have dyspnea or other abnormal respiratory clinical findings such as decreased breath sounds, prolonged expiratory phase, rales, rhonchi, or wheezes .

# Thromboembolism prophylaxis

## Orthopedic surgery
For knee of hip arthroplasty
- The CRISTAL trial found more benefit (mainly from reducing distal DVTs) from Enoxaparin than aspirin (aspirin 100 mg daily or enoxaparin 40 mg daily for 35 days after hip replacement and 14 days after knee replacement).
- However shorter therapy,After an initial 5 days of rivaroxaban, 9 days of aspirin or rivaroxaban may similarly reduce thromboembolism according to the EPCAT II trial.
For knee arthroscopy
- Evidence from trials conflicts:
Low molecular weight heparin did not prevent thromboembolism in the  POT-KAST trial trial published in 2017. There was no routine imaging for outcomes in this study. Average age of patients was 56. The patients were not routinely imaged for thromboembolism.
In comparing their negative results to the two positive studies below, the POT-KAST authors noted "...in both trials, all the participants underwent ultrasonographic screening for venous thromboembolism, at which time questions were asked about possible signs and symptoms. This clearly does not reflect the method for identification of symptomatic venous thromboembolism that is used in general clinical practice and has therefore led to overestimation of the incidences."
Rivaroxaban once-daily rivaroxaban (10 mg) for .seven days may be better than placebo at preventing thromboembolism in the ERIKA trial published in 2016. Average age of patients was 46. All patients received colour-coded Doppler ultrasonography (CCDU) after seven days.
Low molecular weight heparin did prevent thromboembolism as compared to compression stockings in a trial published in 2008. In this trial, "All patients had bilateral, whole-leg, color-coded Doppler ultrasonography at the end of prophylaxis (8 or 15 days)."
- Low molecular weight heparin did not prevent thromboembolism in the  POT-KAST trial trial published in 2017. There was no routine imaging for outcomes in this study. Average age of patients was 56. The patients were not routinely imaged for thromboembolism.
In comparing their negative results to the two positive studies below, the POT-KAST authors noted "...in both trials, all the participants underwent ultrasonographic screening for venous thromboembolism, at which time questions were asked about possible signs and symptoms. This clearly does not reflect the method for identification of symptomatic venous thromboembolism that is used in general clinical practice and has therefore led to overestimation of the incidences."
- In comparing their negative results to the two positive studies below, the POT-KAST authors noted "...in both trials, all the participants underwent ultrasonographic screening for venous thromboembolism, at which time questions were asked about possible signs and symptoms. This clearly does not reflect the method for identification of symptomatic venous thromboembolism that is used in general clinical practice and has therefore led to overestimation of the incidences."
- Rivaroxaban once-daily rivaroxaban (10 mg) for .seven days may be better than placebo at preventing thromboembolism in the ERIKA trial published in 2016. Average age of patients was 46. All patients received colour-coded Doppler ultrasonography (CCDU) after seven days.
- Low molecular weight heparin did prevent thromboembolism as compared to compression stockings in a trial published in 2008. In this trial, "All patients had bilateral, whole-leg, color-coded Doppler ultrasonography at the end of prophylaxis (8 or 15 days)."
- For systematic reviews:
The Cochrane Collaboration concludes "There is moderate- to low-certainty evidence of no benefit from the use of LMWH, aspirin or rivaroxaban in reducing this small risk of PE or symptomatic DVT. There is very low-certainty evidence that LMWH use may reduce the risk of asymptomatic DVT when compared to no treatment but it is uncertain how this directly relates to incidence of DVT or PE in healthy patients"
- The Cochrane Collaboration concludes "There is moderate- to low-certainty evidence of no benefit from the use of LMWH, aspirin or rivaroxaban in reducing this small risk of PE or symptomatic DVT. There is very low-certainty evidence that LMWH use may reduce the risk of asymptomatic DVT when compared to no treatment but it is uncertain how this directly relates to incidence of DVT or PE in healthy patients"