Preoperative medical evaluation of the adult healthy patient

Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper Official reprint from UpToDate® www.uptodate.com ©2016 UpToDate® Preoperative medical evaluation of the adult healthy patient Author Gerald W Smetana, MD Section Editors Andrew D Auerbach, MD, MPH Natalie F Holt, MD, MPH Deputy Editor Lee Park, MD, MPH All topics are updated as new evidence becomes available and our peer review process is complete Literature review current through: Jun 2016 | This topic last updated: Jul 27, 2016 INTRODUCTION — Clinicians are often asked to evaluate a patient prior to surgery The medical consultant may be seeing the patient at the request of the surgeon or may be the primary care clinician assessing the patient prior to consideration of a surgical referral The goal of the evaluation of the healthy patient is to detect unrecognized disease and risk factors that may increase the risk of surgery above baseline and to propose strategies to reduce this risk The evaluation of healthy patients prior to surgery is reviewed here Preoperative assessments for specific systems issues and surgical procedures are discussed separately (See "Evaluation of cardiac risk prior to noncardiac surgery" and "Perioperative medication management" and "Overview of the principles of medical consultation and perioperative medicine" and "Evaluation of preoperative pulmonary risk".) CLINICAL EVALUATION — In general, the overall risk of surgery is extremely low in healthy individuals Therefore, the ability to stratify risk by commonly performed evaluations is limited Screening questionnaire — Screening questions appear on many standard institutional preoperative evaluation forms One validated screening instrument, derived from 100 patients, comprises 17 questions that allowed nurses to identify those patients who would benefit from a formal preoperative evaluation by an anesthesiologist (table 1) [1] The questions chosen for this questionnaire were devised to detect preexisting conditions shown to be associated with perioperative adverse events Age — A number of commonly employed and validated indices consider age as a minor component of preoperative coronary risk (See "Evaluation of cardiac risk prior to noncardiac surgery".) Some studies have found a small increased risk of surgery associated with advancing age [2,3] In a review of 50,000 older adult patients, for example, the risk of mortality with elective surgery increased from 1.3 percent for those under 60 years of age to 11.3 percent in the 80- to 89-year-old age group [3] Among 1.2 million Medicare patients undergoing elective surgery, mortality risk increased linearly with age for most surgical procedures [4] Operative mortality for patients 80 years and older was more than twice that of patients 65 to 69 years old However, age was not a significant predictor of cardiac complications after multivariable analysis in the cohort of patients used to derive a revised cardiac risk index [5] In addition to the minor influence of age on perioperative cardiac risk, there is more robust literature supporting age as an independent risk factor for postoperative pulmonary complications Age was one of the most important patient-related predictors of pulmonary risk, even after adjusting for common age-related comorbidities, in a systematic review [6] (See "Evaluation of preoperative pulmonary risk".) By contrast, some studies have found little relation between age and mortality rates due to surgery One study reported the outcomes of surgery in 795 patients over 90 years of age [7] No patients were Class I as classified by the American Society of Anesthesiologists (ASA) physical status classification (table 2); 80 percent were ASA Class III or greater Despite higher perioperative mortality rates in older adults, of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper survival at two years was no different than the actuarial survival in matched patients not undergoing surgery [7] A larger study of 4315 patients also found a higher perioperative complication and mortality rate in older individuals, but the mortality rate was low [8] Among 31 patients age 100 years and older undergoing surgery requiring anesthesia, perioperative and one-year mortality rates were similar to matched peers from the general population [9] After adjusting for comorbidities more common with age, the impact of age on perioperative outcomes is modest Much of the risk associated with age is due to increasing numbers of comorbidities, which may include cognitive impairment, functional impairment, malnutrition, and frailty [10] Geriatric patients may benefit from preoperative assessments in those areas, but age should not be used as the sole criterion to guide preoperative testing or to withhold a surgical procedure [11] A risk calculator developed by the American College of Surgeons National Surgery Quality Improvement Program may be helpful in assessing preoperative risk in an older patient Exercise capacity — All patients should be asked about their exercise capacity as part of the preoperative evaluation Exercise capacity is an important determinant of overall perioperative risk; patients with good exercise tolerance generally have low risk (See "Evaluation of cardiac risk prior to noncardiac surgery", section on 'Initial preoperative evaluation'.) The American College of Cardiology/American Heart Association guideline on preoperative cardiac evaluation recommends no testing for patients with good exercise capacity (at least metabolic equivalents [METs]) regardless of the risk of the planned procedure (algorithm 1) [12] Patients’ ability to expend ≥4 METs can be assessed by estimates from activities of daily living; activities that expend ≥4 METS include the ability to climb up a flight of stairs, walk up a hill, walk at ground level at miles per hour, or perform heavy work around the house [12] Alternatively, more formal activity scales can be used An observational study of 87 patients found that, compared with the Duke Activity Status Index, subjective assessment by clinicians generally underestimated exercise capacity [13] In general, healthy patients who can perform these activities as part of their daily routine have a low risk for major postoperative complications This was illustrated in a study of 600 consecutive patients undergoing major surgery [14] The investigators defined poor exercise capacity as the inability to either walk four blocks or climb two flights of stairs Patients reporting poor exercise capacity had twice as many serious postoperative complications as those who reported good exercise capacity (20 versus 10 percent, respectively) There was also a difference in cardiovascular complications (10 versus percent), but not in total pulmonary complications (9 versus percent) The importance of functional capacity was confirmed objectively in another report of 847 patients undergoing elective abdominal surgery [15] In this study, poor exercise capacity, confirmed by cardiopulmonary exercise testing, was a stronger predictor of all-cause mortality than any of the conventional cardiac risk factors of the Revised Cardiac Risk Index Medication use — Clinicians should obtain a history of medication use for all patients before surgery and should specifically inquire about over-the-counter, complementary, and alternative medications Aspirin, ibuprofen, and other nonsteroidal antiinflammatory drugs (NSAIDs) are associated with an increased risk of perioperative bleeding Specific inquiry about use of complementary and alternative medications should also be part of the preoperative assessment A detailed discussion of perioperative medication management is presented separately (See "Perioperative medication management".) Obesity — Contrary to popular belief, in noncardiac surgery, obesity is not a risk factor for most major adverse postoperative outcomes, with the exception of pulmonary embolism None of the published and widely disseminated cardiac risk indices for noncardiac surgery include obesity as a risk factor for postoperative cardiac complications of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper Representative studies related to postoperative mortality in noncardiac surgery include: ● In a matched case control study of 1962 patients undergoing noncardiac surgery, obesity was not associated with increased mortality (1.1 percent in obese patients versus 1.2 percent in controls) [16] ● In a large, multi-institutional, prospective cohort of 118,707 patients undergoing non-bariatric general surgery, obesity was inversely associated with postoperative mortality (odds ratio [OR] 0.85, 95% CI 0.75-0.99), a phenomenon termed the “obesity paradox” [17] The authors suggest that the obese state carries a low-grade, chronic inflammatory that may be “primed” to mount an appropriate inflammatory and immune response to the stress of surgery, in addition to supplying more nutritional reserve Other studies relating to complications in noncardiac surgery found that obesity increases rates for wound infections but has no effect on other postoperative complications except for postoperative deep venous thrombosis and pulmonary embolism [6,18-22] (See "Prevention of venous thromboembolic disease in surgical patients".) However, in cardiac surgery, some studies have shown higher complication rates for obese patients, including increased hospital stay [23], wound infections [23,24], prolonged mechanical ventilation [24], and atrial arrhythmias [24,25] Obstructive sleep apnea — Given the increased risks of perioperative morbidity and the potential for altered anesthetic management, it is reasonable to screen patients for obstructive sleep apnea (OSA) before surgery with one of several validated screening instruments OSA increases the risk for postoperative medical complications including hypoxemia, respiratory failure, unplanned reintubation, and intensive care unit (ICU) transfer [26] Most patients with OSA are undiagnosed The prevalence of previously undetected OSA is particularly high in patients preparing for bariatric surgery A detailed discussion of the perioperative risks and the role of screening for OSA is presented elsewhere (See "Surgical risk and the preoperative evaluation and management of adults with obstructive sleep apnea".) Alcohol misuse — Patients who misuse alcohol on a regular basis have an increased risk for postoperative complications [27] Screening for alcohol misuse before surgery will identify a subset of patients at increased risk for postoperative medical complications While the benefit of directed alcohol cessation programs before surgery is not well-established in the literature, there is little apparent risk to such a strategy The preoperative period also serves as an opportunity to identify patients who misuse alcohol and are candidates for intervention as part of primary care follow-up after surgery Pending further study, it is reasonable to screen all patients for alcohol misuse before elective major surgery In a study of 9176 male US veterans, a screening questionnaire for alcohol misuse administered at any time within one year before surgery accurately stratified risk of postoperative complications [28] There was a continuous relationship between postoperative complications and risk scores using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire (table 3) Surgical site infections, other infections, and cardiopulmonary complications each increased across the strata of risk groups based on alcohol use patterns A similarly conducted trial of the AUDIT-C questionnaire before total joint arthroplasty revealed comparable results [29] Patients with high AUDIT-C scores (9 to 12 of 12 possible points) within the year before surgery also have longer lengths of stay, more ICU days, and higher unplanned reoperation rates [30] Most trials of alcohol cessation interventions have been conducted in the nonoperative setting; a small study in patients undergoing colorectal surgery reported a beneficial effect of alcohol screening on postoperative complications [31] The optimal period of cessation is unknown but at least four weeks of abstinence are required to reverse selected physiologic abnormalities [27] of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper Illicit drug use — In order to provide appropriate perioperative care, it is helpful to ask patients about illicit drug use [32] Patients with chronic opioid use may have developed tolerance and require higher than usual doses in the intraoperative and postoperative period Patients who abuse opioids, barbiturates, or amphetamines are at risk for drug withdrawal in the postoperative period (See "Substance use disorder: Principles for recognition and assessment in general medical care".) Smoking — Evaluating tobacco use and offering strategies to quit smoking may reduce postoperative morbidity and mortality, as current smokers have an increased risk for postoperative complications Smoking cessation prior to surgery may reduce the risk of postoperative complications, and longer periods of smoking cessation may be even more effective Smokers should be encouraged to quit immediately preoperatively (See "Strategies to reduce postoperative pulmonary complications in adults", section on 'Smoking cessation' and "Overview of smoking cessation management in adults" and "Behavioral approaches to smoking cessation".) In cohort and case-control studies, preoperative smoking has been associated with an increased risk of postoperative complications, including general morbidity (relative risk [RR] 1.52, 95% CI 1.33-1.74), wound complications (RR 2.15, 95% CI 1.87-2.49), general infections (RR 1.54, 95% CI 1.32-1.79), pulmonary complications (RR 1.73, 95% CI 1.35-2.23), neurological complications (RR 1.38, 95% CI 1.01-1.88), and admission to an ICU (RR 1.60, 95% CI 1.14-2.25) [33] (See "Evaluation of preoperative pulmonary risk", section on 'Smoking'.) Personal or family history of anesthetic complications — Malignant hyperthermia is a rare complication of anesthetic administration that is inherited in an autosomal dominant fashion Due to the morbidity and potential mortality associated with this condition, the preoperative history should include questioning about either a personal or family history of complications from anesthesia (See "Susceptibility to malignant hyperthermia: Evaluation and management" and "Malignant hyperthermia: Clinical diagnosis and management of acute crisis".) LABORATORY EVALUATION — Several review articles in perioperative consultation and most local institutional policies support a selective approach to preoperative testing [34-40] A practice advisory from the American Society of Anesthesiologists (ASA) and a safety guideline from the Association of Anaesthetists of Great Britain and Ireland recommend against routine preoperative laboratory testing in the absence of clinical indications [40,41] Rationale for selective testing — The prevalence of unrecognized disease that influences surgical risk is low in healthy individuals Nevertheless, clinicians often perform laboratory tests in this group of patients out of habit and medicolegal concern, with little benefit and a high incidence of false-positive results Representative studies that have addressed this issue include: ● In a trial of 1061 ambulatory surgical patients randomly assigned to preoperative testing or no testing, there was no difference in perioperative adverse events or events within 30 days of ambulatory surgery [42] Patients assigned to testing could receive a complete blood count, electrolytes, blood glucose, creatinine, electrocardiogram (ECG), and/or chest radiograph, based on the Ontario Preoperative Testing Grid ● Medical consultants commonly see patients before planned cataract surgery In many institutions, guidelines still require routine laboratory testing despite compelling evidence showing no benefit of such testing A systematic review of three randomized trials of testing versus no testing in a total of 21,531 cataract surgeries found that adverse events did not differ between the two groups [43] Institutions may safely eliminate a requirement for routine laboratory tests before cataract surgery ● In a retrospective study of 2000 patients undergoing elective surgery, 60 percent of routinely ordered tests would not have been performed if testing had only been done for recognizable indications; only 0.22 percent of these revealed abnormalities that might influence perioperative of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper management [34] Further chart review determined that these abnormalities were not acted upon, nor did they have adverse surgical consequences ● One report found that only 10 routine laboratory test results in 3782 patients required treatment; just one of these required pharmacologic treatment [44] In a prospective study of 1363 patients for whom laboratory testing was performed at the discretion of the perioperative clinician, only an abnormal ECG predicted postoperative complications Abnormalities in commonly performed blood test and chest radiography had no predictive value [45] ● Investigators performed a retrospective review of 73,596 patients undergoing elective hernia repair using the National Surgical Quality Improvement Program (NSQIP) database [46] Preoperative tests were performed in 63.8 percent of patients; 61.6 percent of these patients had at least one abnormal test result Among patients with no accepted medical indication for testing, 54 percent nonetheless received at least one test After adjustment for demographics, comorbidities, and procedure characteristics, neither preoperative testing nor the finding of an abnormal test result were associated with adverse postoperative outcomes Predictive value — There are several arguments for avoiding routine preoperative tests Normal test values are usually arbitrarily defined as those occurring within two standard deviations from the mean, thereby ensuring that percent of healthy individuals who have a single screening test will have an abnormal result As more tests are ordered, the likelihood of a false-positive test increases; a screening panel containing 20 independent tests in a patient with no disease will yield at least one abnormal result 64 percent of the time (table 4) Thus, the predictive value of abnormal test results is low in healthy patients with a low prevalence of disease (table 5) Aside from possibly causing patient alarm, the additional testing prompted by falsepositive screening tests leads to unnecessary costs, risks, and a potential delay of surgery In addition, clinicians often fail to act upon abnormal test results from routine preoperative testing, thereby creating an additional medicolegal risk A review of studies of routine preoperative testing pooled data and estimated the incidence of abnormalities that affect patient management and the positive and negative likelihood ratios for a postoperative complication (table 6) [35] For nearly all potential laboratory studies, a normal test did not substantially reduce the likelihood of a postoperative complication (the negative likelihood ratio approached 1.0) Positive likelihood ratios were modest, and they exceeded 3.0 for only three tests (hemoglobin, renal function, and electrolytes); however, clinical evaluation can predict most patients with an abnormal result This was illustrated by the low incidence of a change in preoperative management based on an abnormal test result (0 to percent) Timing of laboratory testing — When laboratory tests are felt to be necessary, it is reasonable to use test results that were performed and were normal within the past four months, unless there has been an interim change in clinical status The validity of this approach was illustrated in an observational study which investigated the usefulness of 7549 preoperative tests performed at the time of admission in 1109 patients undergoing elective surgery [37] In 47 percent of cases, the same tests had been performed within the previous year When repeated at admission: ● Of 3096 previously normal tests (performed a median of two months prior to admission), only 13 (0.4 percent) values were outside a range considered acceptable for surgery, and most of these patients had a change in clinical history that predicted the abnormality ● Of 461 previously abnormal tests, when repeated at admission, only 78 (17 percent) remained outside a range considered acceptable for surgery, suggesting that it is useful to repeat abnormal tests in the immediate preoperative period of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper Laboratory studies — While preoperative laboratory testing is not routinely indicated, selective testing is appropriate in specific circumstances, including patients with known underlying diseases or risk factors that would affect operative management or increase risk, and specific high-risk surgical procedures [38] Specific laboratory studies commonly ordered for preoperative evaluation include a complete blood count, electrolytes, renal function, blood glucose, liver function studies, hemostasis evaluation, and urinalysis These tests are discussed below with indications for their use in specific populations and surgeries Complete blood count ● Hemoglobin/hematocrit – A baseline hemoglobin measurement is suggested for all patients 65 years of age or older who are undergoing major surgery and for younger patients undergoing major surgery that is expected to result in significant blood loss By contrast, hemoglobin measurement is not necessary for those undergoing minor surgery unless the history suggests anemia Anemia is present in approximately percent of asymptomatic patients; surgically significant anemia has an even lower prevalence [34] However, anemia is common following major surgery and the preoperative hemoglobin level predicts postoperative mortality As an example, a large observational study of older veterans (n = 310,311, age ≥65 years) found an increase in 30-day postoperative mortality for patients with mildly abnormal preoperative hematocrits undergoing major noncardiac surgery, even in the absence of significant blood loss [47] Adjusted mortality increased by 1.6 percent (95% CI 1.1 to 2.2 percent) for every one percentage point increase or decrease from a normal hematocrit, defined as 39.0 to 53.9 percent The data cannot distinguish whether an abnormal hematocrit serves as a marker for coexistent disease that increases mortality risk, or whether the anemia itself increases physiologic stresses and therefore complication rates The observation that outcomes not differ for patients undergoing hip surgery who were randomly assigned to either liberal or restrictive transfusion policies suggests that anemia is a marker for risk, rather than the cause of morbidity [48] It remains unclear if the increased risk due to anemia is modifiable by interventions aimed at correcting the hematocrit ● White blood cell count and platelets – The frequency of significant unsuspected white blood cell or platelet abnormalities is low [34] It is reasonable to measure platelet count when neuraxial anesthesia (spinal or epidural) is planned Unlike the hemoglobin concentration, however, there is little rationale to support baseline testing of either Nevertheless, obtaining a complete blood count, including white count and platelet measurement, can be recommended if the cost is not substantially greater than the cost of a hemoglobin concentration alone There may be some costs incurred due to follow-up of false-positive results; however, with respect to platelet counts, these costs not appear to be substantial [49] Renal function — It is appropriate to obtain a serum creatinine concentration in patients over the age of 50 undergoing intermediate- or high-risk surgery, although there is no clear consensus on this point It should also be ordered when hypotension is likely, or when nephrotoxic medications will be used Mild to moderate renal impairment is usually asymptomatic; the prevalence of an elevated creatinine among asymptomatic patients with no history of renal disease is only 0.2 percent [34,50] However, the prevalence increases with age In one study, for example, the prevalence among unselected patients aged 46 to 60 was 9.8 percent [51] In the revised cardiac risk index, a serum creatinine >2.0 mg/dL (177 micromol/L) was one of six independent factors that predicted postoperative cardiac complications [5] Renal insufficiency is also an of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper independent risk factor for postoperative pulmonary complications [6] and a major predictor of postoperative mortality [52] Renal insufficiency necessitates dosage adjustment of some medications that may be used perioperatively (eg, muscle relaxants) Electrolytes — Routine electrolyte determinations are NOT recommended unless the patient has a history that increases the likelihood of an abnormality The frequency of unexpected electrolyte abnormalities is low (0.6 percent in one report) [34] While preoperative hypernatremia is associated with an increase in perioperative 30-day morbidity and mortality [53], the relationship between most electrolyte derangements and operative morbidity is not clear Furthermore, clinicians can predict most abnormalities based on history (for example, current use of a diuretic, angiotensin-converting enzyme [ACE] inhibitor, or angiotensin receptor blocker [ARB], or known chronic kidney disease) Blood glucose — Routine measurement of blood glucose is NOT recommended for healthy patients Unexpected abnormal blood glucose results not often influence perioperative management As an example, one study evaluated the benefit of routine laboratory testing in 1010 presumably healthy patients undergoing cholecystectomy [50] Eight patients had unexpected elevations in preoperative serum glucose; only one of these patients developed significant postoperative hyperglycemia, and this was not recognized until after total parenteral nutrition was started No patient in this study benefited from routine preoperative measurement of serum glucose Also, the frequency of glucose abnormalities increases with age; almost 25 percent of patients over age 60 had an abnormal value in one report [51] Most controlled studies have not found a relationship between operative risk and diabetes [2,51], except in patients undergoing vascular surgery or coronary artery bypass grafting [54,55] While the revised cardiac risk index identified diabetes as a risk factor for postoperative cardiac complications, only patients with insulin-treated diabetes were at risk [5] There is no evidence that asymptomatic hyperglycemia, in a patient not previously known to have diabetes, increases surgical risk The rate of asymptomatic hyperglycemia in unselected surgical patients is low; in one report, the incidence was only 1.2 percent [56] Liver function tests — Routine liver enzyme testing is NOT recommended Unexpected liver enzyme abnormalities are uncommon, occurring in only 0.3 percent of patients in one series [44] In a pooled data analysis, only 0.1 percent of all routine preoperative liver function tests changed preoperative management (table 6) [35] In a study of the NSQIP database, among 25,149 patient with no comorbidities, the relative risk for major postoperative complications among patients who received preoperative liver function tests, when compared with those with no testing, approached one (RR 0.94, 95% CI 0.42-2.08) [46] Severe liver function test abnormalities among patients with cirrhosis or acute liver disease are associated with increased surgical morbidity and mortality, but no data suggest that mild abnormalities among patients with no known liver disease have a similar impact [57] Clinically significant liver disease would most likely be suspected on the basis of the history and physical examination Tests of hemostasis — Routine preoperative tests of hemostasis are NOT recommended If the history, physical examination, and family history not suggest the presence of a bleeding disorder, no additional laboratory testing is required If the evaluation suggests the presence of a bleeding disorder, appropriate screening tests should be performed, including prothrombin time (PT), activated partial thromboplastin time (aPTT), and platelet count [58] For some bleeding disorders (eg, inherited platelet disorder, hemophilia carrier), additional tests may be required to establish a diagnosis and identify the degree of abnormality [58,59] (See "Preoperative assessment of hemostasis".) Unexpected significant abnormalities of the PT or PTT are uncommon [34,49] Inherited coagulation defects are quite rare For example, the incidence of hemophilia A and B among men is 1:5000 and 1:30,000, respectively [60] Nearly all of these cases would be evident based on clinical presentation of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper prior to the preoperative medical evaluation In addition, the relationship between an abnormal result and the risk of perioperative hemorrhage is not well-defined but appears to be quite low, particularly in those who are thought to have a low risk of hemorrhage on the basis of history and physical examination [61,62] Even among neurosurgical patients, for whom a small amount of unanticipated bleeding could cause substantial morbidity, the medical history is the most useful screening test for bleeding diathesis In a study of 11,804 patients undergoing spinal or intracranial surgery, a medical history that suggested risk for bleeding complications was substantially more sensitive that PT or PTT values in predicting need for transfusion, unplanned reoperation, and mortality [63] In a pooled data analysis, an abnormal PT had a positive likelihood ratio of for predicting a postoperative complication and a negative likelihood ratio of 1.01 (table 6); in no case did the finding of an abnormal PT change patient management or modify the likelihood of a complication [35] Similarly, the bleeding time is not useful in assessing the risk of perioperative hemorrhage [64,65] Urinalysis — Routine urinalysis is NOT recommended preoperatively for most surgical procedures The theoretical reason to obtain a preoperative urinalysis is detection of unsuspected urinary tract infection Urinary tract infections have the potential to cause bacteremia and postsurgical wound infections, particularly with prosthetic surgery [66] Patients with positive urinalysis and urine culture are generally treated with antibiotics and proceed with surgery without delay [67] However, it is unclear whether a positive preoperative urinalysis and culture with subsequent antibiotic treatment prevent postsurgical infection One study found no difference in wound infection between patients with normal and abnormal urinalysis [68] Another study found that patients with asymptomatic urinary tract infection detected by urinalysis had an increased risk of wound infection postoperatively, despite treatment [69] A cost-effectiveness analysis estimated that 4.58 wound infections in nonprosthetic knee operations may be prevented annually by the use of routine urinalysis, at a cost of $1,500,000 per wound infection prevented [70] Asymptomatic renal disease can be detected by measurement of serum creatinine in selected patients (See 'Renal function' above.) Pregnancy testing — The knowledge that a woman is pregnant substantially changes perioperative management We suggest pregnancy testing in all reproductive-age women prior to surgery The patient may elect to cancel elective surgery, or may decide in collaboration with her clinicians to undertake a different, lower-risk surgery than originally planned In addition, anesthetic technique differs for pregnant women, and there may be risks to the fetus if a pregnancy goes undetected before surgery and anesthesia Guidelines in the United Kingdom recommend always asking about the possibility of pregnancy before surgery and, if pregnancy is possible after history-taking, offering a pregnancy test [71,72] The ASA recommends that clinicians offer pregnancy testing for women of childbearing age if the results would alter management [40] While these guidelines provide some discretion in deciding which women to test, it is often not possible to reliably exclude pregnancy based on medical history-taking alone [73] Many institutions require pregnancy testing for all reproductive age women before surgery There is low risk to this approach; false-positives are rare, testing is inexpensive, and the results return rapidly (See "Clinical manifestations and diagnosis of early pregnancy", section on 'Detection of hCG'.) ELECTROCARDIOGRAM — We suggest NOT ordering an electrocardiogram (ECG) for asymptomatic patients undergoing low-risk surgical procedures ECGs have a low likelihood of changing perioperative management in the absence of known cardiac disease The prevalence of abnormal ECGs increases with age [74] Important ECG abnormalities in patients younger than 45 years with no known cardiac disease are very infrequent The 2014 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines on of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper Perioperative Cardiovascular Evaluation state that ECG is not useful in asymptomatic patients undergoing low-risk procedures [75] Similarly, the European Society of Cardiology 2014 preoperative guidelines not recommend ECG in patients without risk factors [76] The 2014 ACC/AHA guidelines recommend a preoperative resting 12-lead ECG for patients with known coronary artery disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease or other significant structural heart disease, except for those undergoing low-risk surgery (risk of major adverse cardiac event 2.0 mg/dL (177 micromol/L) predicted postoperative cardiac complications We suggest NOT obtaining a serum creatinine concentration, except in the following patients (Grade 2B) (see 'Renal function' above): • Patients over the age of 50 undergoing intermediate or high risk surgery • Younger patients suspected of having renal disease, when hypotension is likely during surgery, or when nephrotoxic medications will be used ● We suggest NOT testing for serum electrolytes, blood glucose, liver function, hemostasis, or urinalysis in the healthy preoperative patient (Grade 2B) We suggest pregnancy testing in all reproductive age women prior to surgery, rather than use of history-taking alone to determine pregnancy (Grade 2C) (See 'Laboratory studies' above.) ● We suggest NOT ordering an electrocardiogram (ECG) for asymptomatic patients undergoing low-risk surgical procedures 10 of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper According to the 2014 American College of Cardiology/American Heart Association (ACC/AHA) guidelines, a resting 12-lead ECG should be part of the evaluation in patients with known coronary artery disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, or other significant structural heart disease, except for those undergoing low-risk surgery A preoperative resting ECG can be considered for asymptomatic patients undergoing surgery with elevated risk (risk of major adverse cardiac event ≥1 percent) This is discussed in detail elsewhere (See 'Electrocardiogram' above and "Evaluation of cardiac risk prior to noncardiac surgery", section on 'Initial preoperative evaluation'.) ● We suggest that clinicians NOT order routine preoperative chest radiographs or pulmonary function tests in the healthy patient (Grade 2B) We suggest obtaining a preoperative chest radiograph in patients with cardiopulmonary disease and those older than 50 years of age who are undergoing abdominal aortic aneurysm surgery or upper abdominal/thoracic surgery (Grade 2C) (See 'Chest radiograph' above and 'Pulmonary function tests' above.) Use of UpToDate is subject to the Subscription and License Agreement REFERENCES Hilditch WG, Asbury AJ, Jack E, McGrane S Validation of a pre-anaesthetic screening questionnaire Anaesthesia 2003; 58:874 Goldman L, Caldera DL, Nussbaum SR, et al Multifactorial index of cardiac risk in noncardiac surgical procedures N Engl J Med 1977; 297:845 Linn BS, Linn MW, Wallen N Evaluation of results of surgical procedures in the elderly Ann Surg 1982; 195:90 Finlayson EV, Birkmeyer JD Operative mortality with elective surgery in older adults Eff Clin Pract 2001; 4:172 Lee TH, Marcantonio ER, Mangione CM, et al Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery Circulation 1999; 100:1043 Smetana GW, Lawrence VA, Cornell JE, American College of Physicians Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians Ann Intern Med 2006; 144:581 Hosking MP, Warner MA, Lobdell CM, et al Outcomes of surgery in patients 90 years of age and older JAMA 1989; 261:1909 Polanczyk CA, Marcantonio E, Goldman L, et al Impact of age on perioperative complications and length of stay in patients undergoing noncardiac surgery Ann Intern Med 2001; 134:637 Warner MA, Saletel RA, Schroeder DR, et al Outcomes of anesthesia and surgery in people 100 years of age and older J Am Geriatr Soc 1998; 46:988 10 Oresanya LB, Lyons WL, Finlayson E Preoperative assessment of the older patient: a narrative review JAMA 2014; 311:2110 11 Lubin MF Is age a risk factor for surgery? Med Clin North Am 1993; 77:327 12 Fleisher LA, Fleischmann KE, Auerbach AD, et al 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines J Am Coll Cardiol 2014; 64:e77 13 Melon CC, Eshtiaghi P, Luksun WJ, Wijeysundera DN Validated questionnaire vs physicians' judgment to estimate preoperative exercise capacity JAMA Intern Med 2014; 174:1507 11 of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper 14 Reilly DF, McNeely MJ, Doerner D, et al Self-reported exercise tolerance and the risk of serious perioperative complications Arch Intern Med 1999; 159:2185 15 Wilson RJ, Davies S, Yates D, et al Impaired functional capacity is associated with all-cause mortality after major elective intra-abdominal surgery Br J Anaesth 2010; 105:297 16 Klasen J, Junger A, Hartmann B, et al Increased body mass index and peri-operative risk in patients undergoing non-cardiac surgery Obes Surg 2004; 14:275 17 Mullen JT, Moorman DW, Davenport DL The obesity paradox: body mass index and outcomes in patients undergoing nonbariatric general surgery Ann Surg 2009; 250:166 18 Dindo D, Muller MK, Weber M, Clavien PA Obesity in general elective surgery Lancet 2003; 361:2032 19 Thomas EJ, Goldman L, Mangione CM, et al Body mass index as a correlate of postoperative complications and resource utilization Am J Med 1997; 102:277 20 Herrera FA, Yanagawa J, Johnson A, et al The prevalence of obesity and postoperative complications in a Veterans Affairs Medical Center general surgery population Am Surg 2007; 73:1009 21 Hofer RE, Kai T, Decker PA, Warner DO Obesity as a risk factor for unanticipated admissions after ambulatory surgery Mayo Clin Proc 2008; 83:908 22 Smetana GW Preoperative pulmonary evaluation N Engl J Med 1999; 340:937 23 Yap CH, Zimmet A, Mohajeri M, Yii M Effect of obesity on early morbidity and mortality following cardiac surgery Heart Lung Circ 2007; 16:31 24 Kuduvalli M, Grayson AD, Oo AY, et al Risk of morbidity and in-hospital mortality in obese patients undergoing coronary artery bypass surgery Eur J Cardiothorac Surg 2002; 22:787 25 Zacharias A, Schwann TA, Riordan CJ, et al Obesity and risk of new-onset atrial fibrillation after cardiac surgery Circulation 2005; 112:3247 26 Kaw R, Pasupuleti V, Walker E, et al Postoperative complications in patients with obstructive sleep apnea Chest 2012; 141:436 27 Tønnesen H, Nielsen PR, Lauritzen JB, Møller AM Smoking and alcohol intervention before surgery: evidence for best practice Br J Anaesth 2009; 102:297 28 Bradley KA, Rubinsky AD, Sun H, et al Alcohol screening and risk of postoperative complications in male VA patients undergoing major non-cardiac surgery J Gen Intern Med 2011; 26:162 29 Harris AH, Reeder R, Ellerbe L, et al Preoperative alcohol screening scores: association with complications in men undergoing total joint arthroplasty J Bone Joint Surg Am 2011; 93:321 30 Rubinsky AD, Sun H, Blough DK, et al AUDIT-C alcohol screening results and postoperative inpatient health care use J Am Coll Surg 2012; 214:296 31 Tonnesen H, Rosenberg J, Nielsen HJ, et al Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers: randomised controlled trial BMJ 1999; 318:1311 32 Kleinwächter R, Kork F, Weiss-Gerlach E, et al Improving the detection of illicit substance use in preoperative anesthesiological assessment Minerva Anestesiol 2010; 76:29 33 Grønkjær M, Eliasen M, Skov-Ettrup LS, et al Preoperative smoking status and postoperative complications: a systematic review and meta-analysis Ann Surg 2014; 259:52 34 Kaplan EB, Sheiner LB, Boeckmann AJ, et al The usefulness of preoperative laboratory screening JAMA 1985; 253:3576 35 Smetana GW, Macpherson DS The case against routine preoperative laboratory testing Med Clin North Am 2003; 87:7 36 Fleisher LA, Beckman JA, Brown KA, et al 2009 ACCF/AHA focused update on perioperative beta 12 of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American college of cardiology foundation/American heart association task force on practice guidelines Circulation 2009; 120:e169 37 Macpherson DS, Snow R, Lofgren RP Preoperative screening: value of previous tests Ann Intern Med 1990; 113:969 38 Macpherson DS Preoperative laboratory testing: should any tests be "routine" before surgery? Med Clin North Am 1993; 77:289 39 García-Miguel FJ, Serrano-Aguilar PG, López-Bastida J Preoperative assessment Lancet 2003; 362:1749 40 Committee on Standards and Practice Parameters, Apfelbaum JL, Connis RT, et al Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation Anesthesiology 2012; 116:522 41 Association of Anaesthetists of Great Britain and Ireland AAGBI safety guideline Pre-operative assessment and patient preparation The role of the anaesthetist January 2010 London http://www.aagbi.org/sites/default/files/preop2010.pdf (Accessed on June 27, 2011) 42 Chung F, Yuan H, Yin L, et al Elimination of preoperative testing in ambulatory surgery Anesth Analg 2009; 108:467 43 Keay L, Lindsley K, Tielsch J, et al Routine preoperative medical testing for cataract surgery Cochrane Database Syst Rev 2012; :CD007293 44 Narr BJ, Hansen TR, Warner MA Preoperative laboratory screening in healthy Mayo patients: cost-effective elimination of tests and unchanged outcomes Mayo Clin Proc 1991; 66:155 45 Fritsch G, Flamm M, Hepner DL, et al Abnormal pre-operative tests, pathologic findings of medical history, and their predictive value for perioperative complications Acta Anaesthesiol Scand 2012; 56:339 46 Benarroch-Gampel J, Sheffield KM, Duncan CB, et al Preoperative laboratory testing in patients undergoing elective, low-risk ambulatory surgery Ann Surg 2012; 256:518 47 Wu WC, Schifftner TL, Henderson WG, et al Preoperative hematocrit levels and postoperative outcomes in older patients undergoing noncardiac surgery JAMA 2007; 297:2481 48 Carson JL, Terrin ML, Noveck H, et al Liberal or restrictive transfusion in high-risk patients after hip surgery N Engl J Med 2011; 365:2453 49 Bushick JB, Eisenberg JM, Kinman J, et al Pursuit of abnormal coagulation screening tests generates modest hidden preoperative costs J Gen Intern Med 1989; 4:493 50 Turnbull JM, Buck C The value of preoperative screening investigations in otherwise healthy individuals Arch Intern Med 1987; 147:1101 51 Velanovich V The value of routine preoperative laboratory testing in predicting postoperative complications: a multivariate analysis Surgery 1991; 109:236 52 Mathew A, Devereaux PJ, O'Hare A, et al Chronic kidney disease and postoperative mortality: a systematic review and meta-analysis Kidney Int 2008; 73:1069 53 Leung AA, McAlister FA, Finlayson SR, Bates DW Preoperative hypernatremia predicts increased perioperative morbidity and mortality Am J Med 2013; 126:877 54 Eagle KA, Coley CM, Newell JB, et al Combining clinical and thallium data optimizes preoperative assessment of cardiac risk before major vascular surgery Ann Intern Med 1989; 110:859 55 Higgins TL, Estafanous FG, Loop FD, et al Stratification of morbidity and mortality outcome by preoperative risk factors in coronary artery bypass patients A clinical severity score JAMA 1992; 267:2344 13 of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper 56 Grek S, Gravenstein N, Morey TE, Rice MJ A cost-effective screening method for preoperative hyperglycemia Anesth Analg 2009; 109:1622 57 Powell-Jackson P, Greenway B, Williams R Adverse effects of exploratory laparotomy in patients with unsuspected liver disease Br J Surg 1982; 69:449 58 Chee YL, Crawford JC, Watson HG, Greaves M Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures British Committee for Standards in Haematology Br J Haematol 2008; 140:496 59 Danielson D, Bjork K, Card R, et al Institute for Clinical Systems Improvement Preoperative Evaluation Available at: http://www.icsi.org/preoperative_evaluation /preoperative_evaluation_2328.html (Accessed on August 30, 2012) 60 van Veen JJ, Spahn DR, Makris M Routine preoperative coagulation tests: an outdated practice? Br J Anaesth 2011; 106:1 61 Suchman AL, Mushlin AI How well does the activated partial thromboplastin time predict postoperative hemorrhage? JAMA 1986; 256:750 62 Sié P, Steib A Central laboratory and point of care assessment of perioperative hemostasis Can J Anaesth 2006; 53:S12 63 Seicean A, Schiltz NK, Seicean S, et al Use and utility of preoperative hemostatic screening and patient history in adult neurosurgical patients J Neurosurg 2012; 116:1097 64 Rodgers RP, Levin J A critical reappraisal of the bleeding time Semin Thromb Hemost 1990; 16:1 65 Peterson P, Hayes TE, Arkin CF, et al The preoperative bleeding time test lacks clinical benefit: College of American Pathologists' and American Society of Clinical Pathologists' position article Arch Surg 1998; 133:134 66 Koulouvaris P, Sculco P, Finerty E, et al Relationship between perioperative urinary tract infection and deep infection after joint arthroplasty Clin Orthop Relat Res 2009; 467:1859 67 David TS, Vrahas MS Perioperative lower urinary tract infections and deep sepsis in patients undergoing total joint arthroplasty J Am Acad Orthop Surg 2000; 8:66 68 Lawrence VA, Kroenke K The unproven utility of preoperative urinalysis Clinical use Arch Intern Med 1988; 148:1370 69 Ollivere BJ, Ellahee N, Logan K, et al Asymptomatic urinary tract colonisation predisposes to superficial wound infection in elective orthopaedic surgery Int Orthop 2009; 33:847 70 Lawrence VA, Gafni A, Gross M The unproven utility of the preoperative urinalysis: economic evaluation J Clin Epidemiol 1989; 42:1185 71 Lamont T, Coates T, Mathew D, et al Checking for pregnancy before surgery: summary of a safety report from the National Patient Safety Agency BMJ 2010; 341:c3402 72 O'Neill F, Carter E, Pink N, Smith I Routine preoperative tests for elective surgery: summary of updated NICE guidance BMJ 2016; 354:i3292 73 Ramoska EA, Sacchetti AD, Nepp M Reliability of patient history in determining the possibility of pregnancy Ann Emerg Med 1989; 18:48 74 Goldberger AL, O'Konski M Utility of the routine electrocardiogram before surgery and on general hospital admission Critical review and new guidelines Ann Intern Med 1986; 105:552 75 Fleisher LA, Fleischmann KE, Auerbach AD, et al 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Circulation 2014; 130:2215 76 Kristensen SD, Knuuti J New ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management Eur Heart J 2014; 35:2344 14 of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper 77 Poirier P, Alpert MA, Fleisher LA, et al Cardiovascular evaluation and management of severely obese patients undergoing surgery: a science advisory from the American Heart Association Circulation 2009; 120:86 78 Smetana GW The Conundrum of Unnecessary Preoperative Testing JAMA Intern Med 2015; 175:1359 79 The Swedish Council on Technology Assessment in Health Care (SBU) Preoperative routines Stockholm: SBU, 1989 80 Agence Nationale pour le Development de l'Evaluation Medicale (ANDEM) Indication of Preoperative Tests Paris: ANDEM, 1992 81 Guidelines and Protocols Advisory Committee (GPAC), Medical Services Commission, and British Columbia Medical Association Guideline for Routine Pre-Operative Testing Victoria BC: Ministry of Health, 2000 82 National Institute for Clinical Excellence (2003) Guidance on the use of preoperative tests for elective surgery NICE Clinical Guideline No London: National Institute for Clinical Excellence, 2003 83 Archer C, Levy AR, McGregor M Value of routine preoperative chest x-rays: a meta-analysis Can J Anaesth 1993; 40:1022 84 Rucker L, Frye EB, Staten MA Usefulness of screening chest roentgenograms in preoperative patients JAMA 1983; 250:3209 85 Lawrence VA, Dhanda R, Hilsenbeck SG, Page CP Risk of pulmonary complications after elective abdominal surgery Chest 1996; 110:744 Topic 4816 Version 51.0 15 of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper GRAPHICS Preoperative medical evaluation questions for a healthy patient Questions Do you usually get chest pain or breathlessness when you climb up two flights of stairs at normal speed? Do you have kidney disease? Has anyone in your family (blood relatives) had a problem following an anaesthetic? Have you ever had a heart attack? Have you ever been diagnosed with an irregular heartbeat? Have you ever had a stroke? If you have been put to sleep for an operation were there any anaesthetic problems? Do you suffer from epilepsy or seizures? Do you have any problems with pain, stiffness or arthritis in your neck or jaw? 10 Do you have thyroid disease? 11 Do you suffer from angina? 12 Do you have liver disease? 13 Have you ever been diagnosed with heart failure? 14 Do you suffer from asthma? 15 Do you have diabetes that requires insulin? 16 Do you have diabetes that requires tablets only? 17 Do you suffer from bronchitis? Data from: Hilditch, WG, Asbury, AJ, Jack, E, McGrane, S Validation of a pre-anaesthetic screening questionnaire Anaesthesia 2003; 58:874 Graphic 66690 Version 1.0 16 of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper American Society of Anesthesiologists (ASA) Physical Status Classification System ASA A normal healthy patient ASA A patient with mild systemic disease ASA A patient with severe systemic disease ASA A patient with severe systemic disease that is a constant threat to life ASA A moribund patient who is not expected to survive without the operation ASA A declared brain-dead patient whose organs are being removed for donor purposes ASA Physical Status Classification System is reprinted with permission of the American Society of Anesthesiologists, 520 N Northwest Highway, Park Ridge, Illinois 60068-2573 Graphic 87504 Version 6.0 17 of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper Stepwise approach to perioperative cardiac assessment for CAD ACS: acute coronary syndrome; CABG: coronary artery bypass graft surgery; CAD: coronary artery disease; CPG: clinical practice guideline; DASI: Duke Activity Status Index; GDMT: guideline-directed therapy; HF: heart failure; MACE: major adverse cardiac event; MET: metabolic equivalent; NB: no benefit; NSQIP: National Surgical Quality Improvement Program; PCI: percutaneous coronary intervention; RCRI: Revised Cardiac Risk Index; STEMI: ST elevation myocardial infarction; UA/NSTEMI: unstable angina/non-ST elevation 18 of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper myocardial infarction; VHD: valvular heart disease Reproduced from: Fleisher LA, Fleischmann KE, Auerbach AD 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines J Am Coll Cardiol 2014 [Epub ahead of print] Illustration used with the permission of Elsevier Inc All rights reserved Graphic 96563 Version 3.0 19 of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper AUDIT-C Question #1: How often did you have a drink containing alcohol in the past year? • Never (0 points) • Monthly or less (1 point) • Two to four times a month (2 points) • Two to three times per week (3 points) • Four or more times a week (4 points) Question #2: How many drinks did you have on a typical day when you were drinking in the past year? • or (0 points) • or (1 point) • or (2 points) • to (3 points) • 10 or more (4 points) Question #3: How often did you have six or more drinks on one occasion in the past year? • Never (0 points) • Less than monthly (1 point) • Monthly (2 points) • Weekly (3 points) • Daily or almost daily (4 points) The AUDIT-C is scored on a scale of to 12 (scores of reflect no alcohol use) In men, a score of or more is considered positive; in women, a score of or more is considered positive Graphic 53246 Version 4.0 20 of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper Probability of an abnormal screening test result Number of independent tests Probability of abnormal test percent 10 percent 19 percent 26 percent 10 40 percent 20 64 percent 50 92 percent Graphic 60009 Version 1.0 21 of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper Predictive value of positive test results Prevalence of disease, percent Predictive value of positive test, percent 0.1 1.9 1.0 16.1 2.0 27.9 5.0 50.0 50.0 95.0 Graphic 55083 Version 1.0 22 of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper Value of preoperative tests in influencing preoperative management and predicting postoperative complications in adults Incidence of abnormalities Test that influence management, percent Positive likelihood ratio Negative likelihood ratio of postoperative of postoperative complication, complication, LR+ LR- Hemoglobin 0.1 3.3 0.90 White blood cell count 0.0 0.0 1.00 Platelet count 0.0 0.0 1.00 Prothrombin time (PT) 0.0 0.0 1.01 Partial thromboplastin time (PTT) 0.1 1.7 0.86 Electrolytes 1.8 4.3* 0.80 Renal function 2.6 3.3 0.81 Glucose 0.5 1.6 0.85 Liver function tests 0.1 NA** NA** Urinalysis 1.4 1.7 0.97 Electrocardiogram 2.6 1.6 0.96 Chest radiograph 3.0 2.5 0.72 *Although the LR+ value is higher for electrolytes than for other preoperative tests, most of these patients could have been selectively identified as candidates for testing based on clinical criteria The authors therefore not recommend routine measurement of preoperative electrolytes **NA = Not available; no studies have reported the incidence of adverse events in a cohort of healthy patients with normal or abnormal liver function tests Reproduced with permission from Smetana, GW, Macpherson, DS The case against routine preoperative laboratory testing Med Clin North Am 2003; 87:7 Copyright © 2003 Elsevier Science Graphic 75939 Version 2.0 23 of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper Contributor Disclosures Gerald W Smetana, MD Nothing to disclose Andrew D Auerbach, MD, MPH Nothing to disclose Natalie F Holt, MD, MPH Nothing to disclose Lee Park, MD, MPH Nothing to disclose Contributor disclosures are reviewed for conflicts of interest by the editorial group When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence Conflict of interest policy 24 of 24 29/07/2016, 21:01 [...]... 21 of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper Predictive value of positive test results Prevalence of disease, percent Predictive value of positive test, percent 0.1 1.9 1.0 16.1 2.0 27.9 5.0 50.0 50.0 95.0 Graphic 55083 Version 1.0 22 of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult. .. McGrane, S Validation of a pre-anaesthetic screening questionnaire Anaesthesia 2003; 58:874 Graphic 66690 Version 1.0 16 of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper American Society of Anesthesiologists (ASA) Physical Status Classification System ASA 1 A normal healthy patient ASA 2 A patient with mild... 35:2344 14 of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper 77 Poirier P, Alpert MA, Fleisher LA, et al Cardiovascular evaluation and management of severely obese patients undergoing surgery: a science advisory from the American Heart Association Circulation 2009; 120:86 78 Smetana GW The Conundrum of Unnecessary... roentgenograms in preoperative patients JAMA 1983; 250:3209 85 Lawrence VA, Dhanda R, Hilsenbeck SG, Page CP Risk of pulmonary complications after elective abdominal surgery Chest 1996; 110:744 Topic 4816 Version 51.0 15 of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper GRAPHICS Preoperative medical evaluation. .. *Although the LR+ value is higher for electrolytes than for other preoperative tests, most of these patients could have been selectively identified as candidates for testing based on clinical criteria The authors therefore do not recommend routine measurement of preoperative electrolytes **NA = Not available; no studies have reported the incidence of adverse events in a cohort of healthy patients with... J Am Coll Cardiol 2014 [Epub ahead of print] Illustration used with the permission of Elsevier Inc All rights reserved Graphic 96563 Version 3.0 19 of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper AUDIT-C Question #1: How often did you have a drink containing alcohol in the past year? • Never (0 points)... alcohol use) In men, a score of 4 or more is considered positive; in women, a score of 3 or more is considered positive Graphic 53246 Version 4.0 20 of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper Probability of an abnormal screening test result Number of independent tests Probability of abnormal test 1 5 percent... Boeckmann AJ, et al The usefulness of preoperative laboratory screening JAMA 1985; 253:3576 35 Smetana GW, Macpherson DS The case against routine preoperative laboratory testing Med Clin North Am 2003; 87:7 36 Fleisher LA, Beckman JA, Brown KA, et al 2009 ACCF/AHA focused update on perioperative beta 12 of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper.. .Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper According to the 2014 American College of Cardiology/American Heart Association (ACC/AHA) guidelines, a resting 12-lead ECG should be part of the evaluation in patients with known coronary artery disease, significant arrhythmia,... preoperative assessment of cardiac risk before major vascular surgery Ann Intern Med 1989; 110:859 55 Higgins TL, Estafanous FG, Loop FD, et al Stratification of morbidity and mortality outcome by preoperative risk factors in coronary artery bypass patients A clinical severity score JAMA 1992; 267:2344 13 of 24 29/07/2016, 21:01 Preoperative medical evaluation of the adult healthy patient http://www.uptodate.com.eproxy1.lib.hku.hk/contents/preoper