The purpose of a pre-operative evaluation is to have a trained healthcare professional assess your overall health status, access and minimize for risk of complications and implement measures to minimize complications and improve recovery for a particular procedure that is planned. Although most emergency procedures do not require medical clearance or pre-op due to urgency and risk is determined at the time of presentation by the surgeon, anesthesiologist, and or an internist. Many minor to moderate risk procedures often require a pre-operative evaluation which ideally should be evaluated several weeks before the operation. During the pre-operative evaluation Dr. Varma focuses on establishing risk factors for the heart, lung, infectious complications, and determine the patient’s functional capacity.
Preoperative History and Physical Examination
The type of surgery, patients co-morbid conditions and age influences the overall risk in pre-operative risk assessment. Dr. Varma will inquire about any chronic medical conditions, particularly of the heart and lungs. A serious underlying heart condition such as unstable angina, myocardial infarction within six weeks and aortic or peripheral vascular surgery place a patient into a high-risk category for peri-operative cardiac complications.
Patients with respiratory disease may benefit from peri-operative use of bronchodilators or steroids and may require a baseline chest X-ray. Patients at increased risk of pulmonary complications should receive instruction in deep-breathing exercises or incentive spirometry pre and post operatively.
Assessment of nutritional status is performed. An albumin level of less than 3.2 mg per dL (32 g per L) suggests an increased risk of complications. Patients deemed at risk because of compromised nutritional status may benefit from pre- and postoperative nutritional supplementation.
Information about the condition for which the surgery is planned, any past surgical procedures and the patient’s experience with anesthesia is determined. Medications (including over-the-counter medications) are generally noted. Drug dosages may need to be adjusted in the peri-operative period. Aspirin, blood thinners and non-steroidal anti-inflammatory drugs may need to be discontinued one week before surgery to avoid excessive bleeding. Immunization history, smoking history and alcohol and drug use are established. Ideally, the patient should quit smoking eight or more weeks before surgery to minimize the surgical risk associated with smoking.
A functional assessment is performed and Dr. Varma will review the patient’s social support and need for assistance after hospital discharge. A risk and benefits discussion for the planned procedure and respective goals of care and advance directives established.
Cardiovascular disease affects 25 percent of the U.S. population, and cardiovascular disease is the leading cause of death in the United States, with more than 60 percent of cardiovascular-related deaths due to coronary artery disease. Cardiac complications are the most common type of complication that can threaten the surgical patient’s life or prolong the patient’s hospital stay.
- Major clinical predictors of poor outcome include
- Heart Attack (Myocardial infarction) ≤ 6 weeks previously, Unstable angina, Decompensated congestive heart failure, Significant arrhythmias (e.g., causing hemodynamic instability), Severe valvular disease (e.g., aortic or mitral stenosis with valve area < 1.0 cm2),
- You may still be have minor to intermediate risk if you have – Mild angina pectoris, Myocardial infarction > 6 weeks previously, Compensated congestive heart failure, Diabetes mellitus, Advanced age, Abnormal electrocardiogram, Cardiac rhythm other than sinus, Low functional capacity, History of stroke, uncontrolled hypertension.
The major pulmonary complications in the peri-operative period are atelectasis, pneumonia and bronchitis. Predisposing risk factors include cough, dyspnea, smoking, a history of lung disease, obesity and abdominal or thoracic surgery. The most significant of these risk factors is the site of surgery, with abdominal and thoracic surgery having pulmonary complication rates ranging from 30 to 40 percent.
Patients who smoke cigarettes should be advised to quit smoking for eight weeks before surgery.
Pulmonary complications may be prevented by providing patients with instructions on how to perform incentive spirometry and deep-breathing exercises. Deep-breathing exercises and incentive spirometry in the postoperative period may be particularly beneficial in obese patients, in patients with lung disease and in patients undergoing abdominal or thoracic procedures.
Patients that are malnourished experience increased surgical morbidity and mortality. During your visit Dr. Varma will conduct a complete pre-operative history and physical examination which includes an assessment of risk factors for malnutrition. There are many factors that are associated with malnutrition and these include social isolation, limited financial resources, poor dentition, weight loss and chronic disorders such as pulmonary disease, congestive heart failure, depression, diarrhea and constipation. Surgery may need to be postponed until nutritional supplementation is provided pre-operatively. Post operative there is often an expected period before and after surgery where patients cannot eat foot for a varying period of time. A weight loss of more than 5 percent in one month or of 10 percent or more over six months, a serum albumin of less than 3.2 g per dL (32 g per L), and a total lymphocyte count of less than 3,000 per μL3 (3.0 × 109 per L) can signify an increased risk of postoperative complications.