General Health Assessment
The initial diagnostic workup of the surgical patient is focused on the cause of the presenting complaints. Except in strictly minor
surgical illness, this initial workup should be supplemented by
a complete assessment of the patient’s general health.
This evaluation, which should be completed prior to all major operations, seeks
to identify abnormalities that may influence operative risk or may
have a bearing on the patient’s future well-being. Preoperative
evaluation includes at least a complete history and physical examination.
The evaluation should initially focus on the clinical assessment
of risk based on the patient’s history and current symptoms.
This assessment should guide the remainder of the evaluation. Bleeding
tendencies, medications currently being taken, and allergies and reactions
to antibiotics and other agents should be noted and prominently
displayed on the chart. Previous personal or familial complications
such as venous thromboembolism affect the risk of similar complications
going forward and require active management to decrease the risk.
The physical examination should be thorough and must include neurologic examination and assessment of peripheral arterial pulses
(carotid, radial, femoral, popliteal, posterior tibial, and dorsalis
pedis). The adequacy of circulating blood volume can be determined
by the adequacy of peripheral perfusion, the fullness of neck veins
in the supine and partially erect positions, and tests for orthostatic
changes in blood pressure and pulse. Severe cardiovascular disease
will make these parameters much more difficult to interpret. Patients
who are prone to a hypovolemic state include those with significant
weight loss as a result of cancer, gastrointestinal disease, or
drugs such as diuretics. Peripheral vascular disease should be suspected
if there is a history of transient ischemic attacks, claudication,
or diabetes. If a carotid bruit is found, other studies may be indicated
to specifically evaluate for stenosis. Rectal examination and pelvic
examination should be performed as dictated by the patient’s specific
disease and health-maintenance examination schedule.
All significant complaints, physical findings, and test abnormalities should be adequately evaluated by appropriate further tests, examinations,
and consultations. Practice in the United States has generally included
a complete blood count and serum electrolyte measurements for patients
over 40 and a chest x-ray and electrocardiogram for those over 50.
Although these recommendations are simple to apply, they are not
entirely supported by the medical literature and may result in more
testing than is absolutely necessary. All test results must be interpreted
in the context of the individual patient. For example, a hemoglobin
of 8 g/dL is generally physiologically safe for tissue
oxygen delivery but may be inadequate in the patient with reduced
cardiac output. The adequacy of liver and kidney function should
be tested if impairment is suspected, because each organ plays a major
role in the response to and clearance of various anesthetic agents
both preoperatively and intraoperatively. Selection of the ideal
agent depends on recognition of liver or renal impairment in the
preoperative period. Psychiatric consultation should be considered
in patients with a history of significant mental disorder that may
be exacerbated by operation and in patients whose complaints may
have a psychoneurotic basis.
If the scheduled procedure will or may require blood replacement, the preoperative preparation should include planning for that possibility.
Appropriate strategies may include storing autologous blood in the
weeks prior to operation to allow reinfusion, directed-donor blood
storage for transfusion, or phlebotomy and hemodilution immediately
preoperatively with subsequent reinfusion.
In summary, the preoperative evaluation should be comprehensive to assess the patient’s overall state of health, to determine
the risk of the impending surgical treatment, and to guide the preoperative preparation.
Garcia-Miguel FJ, Serrano-Aguilar PG, Lopez-Bastida J: Preoperative assessment. Lancet 2003;362:1749.
Halaszynski TM, Juda R, Silverman DG: Optimizing postoperative outcomes with efficient preoperative assessment and management.
Crit Care Med 2004;32:S76.
Specific Factors Affecting Operative Risk
The Compromised or Altered Host
Patients may be considered compromised or altered hosts if significant impairment of systems and tissues does not permit a normal response to operative trauma or infection. Preoperative recognition of an abnormal nutritional
or immune state is of obvious importance.
Malnutrition leads to a significant increase in the operative death rate. Weight loss of more than 20% caused by illness such
as cancer or intestinal disease not only results in a higher death
rate but also a greater than threefold increase in the postoperative infection
rate. There is no one best way to determine nutritional status,
but it is clear that dietary history is of major importance in the
assessment, as is a working knowledge of the basic nutritional deficiencies
associated with certain disease states, particularly vitamin deficiencies.
Standard biochemical parameters that indicate impairment in the
visceral protein mass include a serum albumin of less than 3 g/dL
or a serum transferrin of less than 150 mg/dL.
Even when malnutrition is diagnosed, the utility of short-term (7–10 days) preoperative hyperalimentation is not clear.
It is known that nutrition can improve wound healing and immune
function. Current indications for supportive measures before elective
surgery include a history of weight loss in excess of 10% of
body weight or an anticipated prolonged postoperative recovery period
during which the patient will not be fed orally.
Assessment of Immune Competence
Increased knowledge and appreciation of immune defenses has led to a greater awareness of the increased postoperative rates of complications and death due to infection in patients with immune deficiency disorders.
Many immune deficiency states are linked to malnutrition. Total
lymphocyte count and cell-mediated immunity measurement are the
two most commonly performed tests. Anergy or impaired immunity is
diagnosed if no response is noted to any of the skin tests, whereas
a positive response (5 mm or more of induration at the test site)
to one or more skin tests indicates normal lymphocyte activity.
Anergy is associated with an increased susceptibility to infectious complications.
Other more specific tests include neutrophil chemotaxis and measurements
of specific lymphocyte populations. Patients at high risk for immune deficiency
in whom this information is helpful include elderly patients and
those with malnutrition, severe trauma or burns, or cancer.
Other Factors Leading to Increased Infection
Certain drugs may reduce the patient’s resistance to infection by interfering with host defense mechanisms. Corticosteroids, immunosuppressive agents, cytotoxic drugs, and prolonged antibiotic therapy are associated
with an increased incidence of invasion by fungi and other organisms
not commonly encountered in infections. A high rate of wound, pulmonary, and
other infections is observed in renal failure, presumably as a result
of decreased host resistance. Granulocytopenia and diseases that
may produce immunologic deficiency—eg, lymphomas, leukemias,
and hypogammaglobulinemia—are frequently associated with
septic complications. The uncontrolled diabetic patient is also
more susceptible to infection.
The patient with compromised preoperative pulmonary function is susceptible to postoperative pulmonary complications, including
hypoxia, atelectasis, and pneumonia. Preoperative evaluation of
the degree of respiratory impairment is necessary in patients at
high risk for postoperative complications. This evaluation includes
a history of heavy smoking and cough, obesity, advanced age, and known
pulmonary disease, particularly before major intrathoracic or upper abdominal
surgery. Pertinent factors in the history include the presence and character
of cough and excessive sputum production, history of wheezing, and exercise
tolerance. Pertinent physical findings include the presence of wheezing
or prolonged expiration. A chest x-ray, ECG, blood gases, and some
basic pulmonary function tests are useful preoperative studies in
these patients. Although evaluation of arterial oxygen tension is
helpful, the main reason for obtaining preoperative blood gases
is to evaluate for CO2 retention, which indicates severe
pulmonary dysfunction. If surgery is necessary, supplemental oxygen
must be used carefully in the postoperative period, because overuse
may accentuate CO2 retention and aggravate concomitant respiratory
acidosis. The most helpful screening pulmonary function tests are forced
vital capacity (FVC) and forced expiratory volume in 1 second (FEV1).
Values less than 50% of predicted, based on age and body
size, indicate significant airway disease with a high risk for complications.
Preoperative pulmonary preparation for a period as short as 48 hours has been shown to significantly decrease postoperative complications.
Even a few days of abstinence from smoking will decrease sputum
production. Oral or inhaled bronchodilators along with twice-daily
chest physical therapy and postural drainage will help clear inspissated secretions
from the airway. Before operation, patients should be instructed
in techniques of coughing, deep breathing, and use of one of the
incentive spirometry devices that increase inspiratory effort.
Lawrence VA, Cornell JE, Smetana GW: Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery:
systematic review for the American College of Physicians. Ann Intern
This problem can be anticipated in certain categories of patients whose tissue repair process may be compromised. Important factors
include protein depletion, ascorbic acid deficiency, marked dehydration
or edema, severe anemia, diabetes mellitus, and smoking. The most
important component is maintenance of adequate blood volume and
perfusion. Decreased perfusion results in a marked decrease in tissue oxygen
tension, which in turn correlates with delayed wound healing or
infection. Often the decrease is not clinically evident, but it
can be expected to occur in patients receiving chronic diuretic
therapy or those with underlying myocardial dysfunction. Large doses
of corticosteroids depress wound healing in humans. Wounds in patients
who have received appreciable doses of corticosteroids preoperatively
should be closed with special care to prevent disruption and managed postoperatively
as though healing will be delayed.
Operation can be required on a patient receiving cytotoxic chemotherapy for malignancy. These drugs usually interfere with cell proliferation
and tend to decrease the tensile strength of the surgical wound.
Although experimental evidence to support this assumption is equivocal,
it is wise to manage wounds in patients receiving cytotoxic drugs
as though healing will be slower than normal.
Decreased vascularity and other local changes occur after a few weeks or months in tissues that have been heavily irradiated. These
are potential deterrents to wound healing; surgical incisions in
patients who have been irradiated must be planned to avoid complications
due to delayed healing in these areas if possible. Radiation therapy
at levels of 3000 cGy or more are injurious to skin and to connective
and vascular tissues. Chronic changes include scarring, damage to
fibroblasts and collagen, and degenerative changes with subsequent hyalinization
in the walls of blood vessels. Angiogenesis, observable as the capillary
budding in granulation tissue and collagen formation, is inhibited
when these changes are well established, so that surgical wounds
in heavily irradiated tissues will heal slowly or may break down
in the presence of infection. When radiation is given prior to operation,
there is an optimal delay period (2–12 weeks) after completion
of the radiation therapy before operation is performed in order
to minimize wound complications. Technical problems in correctly
timed operations for cancer are not usually increased by low-dosage
(2000–4000 cGy) adjunctive radiotherapy. With radiation
dosage in the therapeutic range (5000–6000 cGy), there
is an increased incidence of wound complications, though this can
be minimized by careful surgical technique and proper timing.
Drug allergies, sensitivities, and incompatibilities and adverse drug effects that may be precipitated by operation must be foreseen
and, if possible, prevented. A history of skin or other untoward
reactions or sickness after injection, oral administration, or other
use of any of the following substances should be noted so they can
- Penicillin or other antibiotic
- Morphine, codeine, meperidine, or other opioid
- Procaine or other anesthetic
- Aspirin or other analgesic
- Tetanus antitoxin or other serum
- Iodine, thimerosal (Merthiolate), or other germicide
- Any other medication
- Any foods such as eggs, milk, or chocolate
- Adhesive tape
A personal or strong family history of asthma, hay fever, or other allergic disorder should alert the surgeon to possible hypersensitivity
Drugs currently or recently taken by the patient may require continuation, dosage adjustment, or discontinuation.
Perioperative Management of Chronic Medications
Beta blockers (metoprolol, atenolol, others)
Ace inhibitors (ACEI) & angiotensin receptor blockers (ARB)
(captopril, lisinopril, losartan, candesartan, others)
Calcium channel blockers (nifedipine, diltiazem, others)
Nitrates (nitroglycerin, isosorbide, others)
Alpha-2 agonists (clonidine, others)
Aspirin or clopidogrel (Plavix)
Oral anticoagulants (warfarin, coumadin)
Diuretics (furosemide, hydrochlorothiazide, others)
Cardiac rhythm management medications (digoxin, beta-blockers,
quinidine, amiodarone, others)
Statins (atorvastatin, simvastatin, others)
Central Nervous System Medications
Anticonvulsants (phenytoin, Tegretol, others)
Antidepressants (imipramine, sertraline, others)
Monoamine oxidase inhibitors (very rarely used)
Antianxiety medications (diazepam, lorazepam, others)
Antipsychotics (haloperidol, Risperdal, others)
Antiparkinson drugs (Sinemet, others)
Recreational drugs (marijuana, cocaine, others)
Night before procedure
Patient taking evening or bedtime insulin
• Neutral protamine Hagedorn (NPH)/Levemir (detemir): give usual dose
• Mixed insulins (70/30, 75/25, etc): give usual dose
• Lantus (glargine): give 80% of usual dose
Patients using insulin pump
Morning of procedure (for patients who are NPO)
Morning insulin injections
Morning intermediate or long-acting insulin
• NPH/Levemir (detemir): give one half usual morning dose
• Lantus (glargine): give 80% of usual morning dose
• Mixed insulin: give one third usual morning dose
Morning short-acting insulin (Novolog, Humalog, Apidra, regular)
Patients using insulin pump
Thyroid medications (Synthroid, desiccated thyroid, propylthiouracil, others)
Steroids (prednisone, Cortef, others)
Phosphate binders, renal vitamins, iron, erythropoietin, others
Opiate-containing analgesics (Vicodin, Tylox, methadone, others)
Nonsteroidal anti-inflammatory compounds (ibuprofen, naproxen, others)
Sublingual buprenorphine (Suboxone and Subutex)
Gastroesophageal reflux disease (GERD) medications (ranitidine, omeprazole, others)
Antiemetics (ondansetron, metaclopramide, others)
Increased risk factors for deep vein thrombophlebitis and pulmonary embolus include cancer, obesity, myocardial dysfunction, age over
45 years, and a prior history of thrombosis. Prophylaxis and treatment
of venous thrombotic disease are discussed in Chapter 35.
Operative risk should be judged on the basis of physiologic rather than chronologic age, and an elderly patient should not be denied
a needed operation because of age alone. The hazard of the average
major operation for the patient over age 60 years is increased only slightly
provided there is no cardiovascular, renal, or other serious systemic
disease. Assume that every patient over 60—even in the
absence of symptoms and physical signs—has some generalized
arteriosclerosis and potential limitation of myocardial and renal
reserve. Accordingly, the preoperative evaluation should be comprehensive.
Administer intravenous fluids with care so as not to overload the circulation. Monitoring of intake, output, body weight, serum
electrolytes, and central venous pressure is important in evaluating
cardiorenal response and tolerance in this age group.
Aged patients generally require smaller doses of strong narcotics and are frequently depressed by routine doses. Codeine is usually
well tolerated. Sedative and hypnotic drugs often cause restlessness,
mental confusion, and uncooperative behavior in the elderly and
should be used cautiously. Preanesthetic medications should be limited
to atropine or scopolamine in the debilitated elderly patient, and
anesthetic agents should be administered in minimal amounts.
Obese patients have an increased frequency of concomitant disease and a high incidence of postoperative wound complications. A controlled preoperative weight loss program is often beneficial before elective procedures.
Halaszynski TM, Juda R, Silverman DG: Optimizing postoperative outcomes with efficient preoperative assessment and management.
Crit Care Med 2004;32:S76.
Preoperative Hemostatic Evaluation
Surgery challenges hemostasis. A patient’s risk of bleeding from surgery depends not only on any preexisting hemostatic defect
but also on the extent, site, and type of surgical procedure being performed.
All patients should be evaluated for their risk of bleeding based
on the specific surgery being planned.
Preoperative hemostatic assessment begins with a comprehensive personal history for bleeding tendencies. This provides the basis
for further diagnostic studies and helps assess the probability of
future bleeding. Patients should be asked about epistaxis, gingival
bleeding, bruising, ecchymoses, and menorrhagia. A history of mucocutaneous bleeding
at these sites suggests von Willebrand disease (vWD), thrombocytopenia,
or functional platelet disorders. A history of excessive bleeding
during or following circumcision, tonsillectomy, tooth extraction,
other surgeries, or during childbirth can be very helpful in uncovering
a hemostatic disorder. It is important to obtain an accurate history
of drug intake, as medications like aspirin, nonsteroidal anti-inflammatory
drugs (NSAIDs), clopidogrel, and warfarin impair hemostasis.
Routine preoperative prothrombin time (PT) and activated partial thromboplastin time (aPTT) testing is unnecessary in patients scheduled
for low-risk surgery and can be reserved for the preoperative workup
in patients scheduled for high-risk surgery. Initial laboratory
testing includes PT, aPTT, complete blood count (CBC), examination
of the blood smear, and biochemical tests of hepatic and renal function.
Bleeding time does not predict abnormal surgical bleeding and is
not routinely recommended. If a screening test is positive, specific
tests to rule out deficiencies of individual coagulation factors,
von Willebrand factor (vWF), and platelet function defects are performed.
Laboratory workup and diagnosis during the initial assessment allows
for appropriate perioperative management.
Dagi TF: The management of postoperative bleeding.
Surg Clin North Am 2005;85:1191.
The opinion of a qualified consultant should be obtained when it may be of benefit to the patient, when requested by the patient
or family members, or when it may be of medicolegal importance.
The physician should take the initiative in arranging consultation
when the treatment proposed is controversial or exceptionally risky,
when dangerous complications occur, or when the physician senses
that the patient or family members are unduly apprehensive regarding
the plan of management or the course of events. Consultation with cardiac
or other medical or surgical specialists preoperatively is important
if the patient has abnormal findings in their fields of competence.
It is also beneficial for the specialist consultant to become acquainted
with the patient and the condition preoperatively when the possibility
exists that the consultant will be called upon for advice later
in connection with a postoperative complication or development.