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Valoracion Preoperatoria

The document discusses the importance of preoperative evaluation for noncardiac surgery in adults, outlining the components and processes involved in assessing a patient's medical conditions and perioperative risks. It emphasizes the need for comprehensive evaluations by various healthcare providers, including preanesthesia assessments, to optimize patient outcomes and inform surgical decisions. Additionally, it highlights the significance of risk assessment tools and the impact of patient factors on surgical outcomes and costs associated with complications.

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0% found this document useful (0 votes)

22 views78 pages

Valoracion Preoperatoria

Uploaded by

Rebeca Ramírez

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as PDF, TXT or read online on Scribd

You are on page 1/ 78

10/3/25, 10:08 p.m.

UpToDate

Official reprint from UpToDate®

Preoperative evaluation for noncardiac surgery in adults

AUTHORS: BobbieJean Sweitzer, MD, FACP, SAMBA-F, FASA, Kurt Pfeifer, MD, FACP, SFHM
SECTION EDITORS: Natalie F Holt, MD, MPH, Andrew D Auerbach, MD, MPH
DEPUTY EDITORS: Marianna Crowley, MD, Jane Givens, MD, MSCE

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Feb 2025.

This topic last updated: Jan 15, 2025.

INTRODUCTION

All patients who undergo surgery must have a preoperative evaluation to assess the patient's
medical conditions, perioperative risk, and readiness for the planned procedure. In addition or
simultaneously, patients who undergo anesthesia must have a preanesthesia evaluation to
create an anesthetic plan. This topic will discuss the components of preoperative evaluation,
including risk assessment and assessment for conditions that increase risk.

Preoperative testing is discussed separately. (See "Preoperative testing for noncardiac

surgery".)

Preoperative medication management is discussed separately. (See "Perioperative medication

management".)

APPROACH TO PREOPERATIVE EVALUATION

The authors use preoperative evaluation as an opportunity to comprehensively assess and

improve a patient’s clinical status. Even for a primary care provider seeing a long-term patient, a
preoperative visit affords the opportunity to reassess the patient and identify issues which have
not been addressed adequately due to other priorities.

COMPONENTS OF THE PROCESS

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Preoperative history and physical examination — Preoperative evaluation (ie, the

preoperative history and physical examination) may be performed by surgeons, primary care
physicians, specialists, anesthesiologists, and advanced practice providers.

All preoperative evaluations should include the following:

● Identify medical conditions, allergies, and previous complications of anesthesia

● Confirm current medications, including over-the-counter medications and supplements

● Review pertinent existing diagnostic studies and order appropriate testing

● Manage and optimize medical diseases that affect perioperative risk

● Assess perioperative risk to inform shared decisions on alternatives for care and options for
anesthesia

● Motivate patients to make positive health behavior changes, including smoking cessation,
weight loss if appropriate, and other preventive care

● Provide instructions for preoperative medication management and fasting

● Meet regulatory requirements where applicable

Preanesthesia evaluation — The preanesthesia evaluation must be performed by an

anesthesia provider. Preanesthesia evaluations should accomplish the following (see 'Timing
and logistics of preoperative evaluation' below):

● Create a plan for anesthesia and postoperative care

● Educate patients and families about anesthesia care

● Determine the appropriate setting for care (eg, hospital, ambulatory setting, or remote
location) (see "Office-based anesthesia", section on 'Patient selection')

We agree with the American Society of Anesthesiologists (ASA) Practice Advisory for
Preanesthesia Evaluation [1] that the preanesthesia assessment includes, at a minimum, the
following:

● Patient interview

● Focused examination of the airway, lungs, and heart

● Review of pertinent medical records

● Indicated preoperative tests

● Consultations with specialists if necessary

TIMING AND LOGISTICS OF PREOPERATIVE EVALUATION

Timing and visit type — The most appropriate clinician to perform the preoperative evaluation
and the timing of the assessment depends upon the patient’s general health, their relationship
with other care providers, the degree of risk associated with the planned procedure, and the
urgency of the procedure. Other patient factors (eg, language barrier, intellectual disability)
may also affect the decision on timing, method, and location of the evaluation. Not all patients
will benefit from the same approach to preoperative evaluation, and resources need to be
matched with expected benefits. In general:

● Patients who are <65 years old who have stable, adequately treated mild medical conditions,
and undergoing low-risk procedures can usually have their preoperative evaluation
completed by any clinician, including the surgeon, and be seen by the anesthesia clinician on
the day of the procedure immediately before anesthesia.

● Intermediate and high-risk patients or patients having high-risk procedures require further
evaluation, time for medical interventions, and intensive planning well in advance of the
procedure [2]. (See 'Assessment for conditions that increase perioperative risk' below.)

● We perform evaluation in advance for patients >65 years of age unless they are having low
risk procedures with monitored anesthesia care.

Much of the literature on the benefits of early preoperative evaluation involves

anesthesiology-directed preoperative clinics. As examples, evaluation of high-risk patients in
such preoperative clinics may reduce unnecessary testing [3,4], case cancellations, [5] delays
on the day of surgery [6], length of stay [7] and mortality [8,9]. Dedicated preoperative clinics
have become increasingly common and may be staffed by anesthesiologists, internists, family
medicine physicians, and/or advanced practice providers.

The greatest benefits to early preoperative anesthesia consultation appear to be in high-risk

patients (eg, those with ischemic heart disease, ASA-PS ≥4, frailty) having intermediate-to high-
risk surgeries (eg, vascular surgery) [8].

In addition to potential morbidity and/or mortality benefits, early preoperative evaluation may
provide other health benefits beyond surgical outcomes (eg, smoking cessation).

Triage and screening — Many centers have created screening guidelines to triage patients for
the timing and method of preoperative evaluation. Examples of patient and procedure triage
criteria are provided ( table 1).

Screening optimally occurs as soon as a procedure is considered. Screening information can be

completed by the patient or family member/guardian in person (paper or electronic version),
remotely via electronic health record tools, with web-based programs, or during a telephone
interview. Examples of screening forms used by contributors to this topic are provided
( table 2 and table 3). At one author’s institution, information in the electronic record
combined with the risk of the planned surgery are used to direct the type of preoperative visit
(eg, nurse phone call, advanced practice provider tele-visit or an in-person visit) via an
algorithm. At the other’s center, patient factors and the type of planned surgery are used to
determine the type of provider seeing the patient in the preoperative clinic (advanced practice
provider, internist, or anesthesiologist).

RISK ASSESSMENT

Assessment of the patient's perioperative risk is an important component of the preoperative

evaluation. Perioperative risk reflects both the risks associated with the patient's medical
conditions and the risk associated with the planned procedure.

● Perioperative assessment of the risks of complications, mortality, likelihood of return to

independent living, and the patient’s goals is part of informed consent and may affect shared
decisions regarding surgical and nonsurgical options for treatment, anesthesia options, and
advanced directives.

● Elevated risk may suggest the need for preoperative intervention, in-hospital or inpatient
rather than ambulatory care, and/or enhanced postoperative monitoring and care (eg,
intensive care, post-discharge skilled nursing facility).

● Risk assessment informs the plan for anesthesia, including the venue for the procedure, type
of anesthesia, intraoperative monitoring, and required resources.

Epidemiology of perioperative complications — Perioperative complications are a major

public health issue and a significant cause of avoidable morbidity and mortality [10,11].
Mortality rates vary widely across hospitals and countries [12,13].

● More than 313 million surgeries are performed annually around the world, and up to 7.7
percent of patients will die within 30 days [14,15]. An estimated 15 million surgical procedures

are performed annually in the United States [16]. Postoperative mortality within 30 days is the
third leading cause of death on a global scale and in the United States [13,17-19].

● As many as 15 percent of patients will have 30-day postoperative complications [19,20]. The
incidence of complications varies across procedures [21] and patient populations. Patients at
highest risk are those of advanced age with comorbid diseases having major surgery, who
have a hospital mortality rate as high as 12 percent [18]. Low socioeconomic status is
associated with higher postoperative mortality, complications, and a lower likelihood of
returning home after surgery [22-24]. Frailty, American Society of Anesthesiologists physical
status (ASA-PS) class 3-5 and increasing numbers of comorbid conditions predict
complications and mortality [18,25].

● Long-term survival is significantly reduced for those patients who have perioperative
complications, even if they survive to leave the hospital [10,26].

● The costs associated with complications after surgery are substantial. In one study, mean
hospital costs were $19,626 (119 percent) higher for patients with complications ($36,060)
compared with those without complications ($16,434) [27]. More than $31.35 billion per year
is spent on perioperative complications in the United States alone [20].

Patient risk factors for perioperative morbidity and mortality

ASA physical status — The ASA-PS is a classification system that defines the overall health
status of the patient and is used by anesthesiologists, surgeons, and other clinicians involved
in perioperative care ( table 4). An ASA-PS rating is assigned to every patient who
undergoes anesthesia. The ASA-PS was not designed to evaluate patient risks, but it is widely
used for this purpose. The ASA-PS only considers patient-level risk factors and not the surgical
risk.

ASA-PS designation is subjective, and assignments vary widely among clinicians, especially
when determined by non-anesthesiologists [28,29]. Nonetheless, a higher ASA-PS class is
associated with complications, increased cost, unexpected hospital admission after
ambulatory surgery, postoperative admission to the intensive care unit, hospital length of
stay, and mortality ( figure 1) [28,30-35].

ASA-PS aligns with Revised Cardiac Risk Index (RCRI) and the Charlson Comorbidity Index as
an assessment of disease burden and health of patients [28,36]. The ASA-PS is a component
of some more comprehensive tools for assigning perioperative risk. (See 'Risk assessment
tools' below.)

Functional capacity — Functional capacity has been shown to predict an increased risk of
postoperative cardiopulmonary complications after major noncardiac surgery [37-39]. A
metabolic equivalent capacity of less than 4 or a Duke Activity Status Index (DASI) less than 34
are key components of the 2024 ACC/AHA recommendations to consider stress testing before
surgery [40]. We use the DASI to assess functional capacity, as it may more reliably predict
surgical risk than subjective assessment [41-43]. (See 'Assessing functional capacity' below.)

In general, healthy patients with moderate (or better) functional capacity have a low risk for
major postoperative complications [44].

● In a study of 600 consecutive patients undergoing major surgery, poor exercise capacity
was defined as the inability to either walk four blocks or climb two flights of stairs [37].
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 5
percent), but not in total pulmonary complications (9 versus 6 percent).

● The importance of functional capacity was demonstrated in a retrospective study of 847

patients undergoing elective major abdominal surgery [45]. 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 RCRI.

● In an international prospective cohort study of 1400 surgical patients (the METS trial), peak
oxygen consumption on cardiopulmonary exercise testing was found to correlate with in-
hospital moderate and severe complications [46].

Functional status as a predictor of perioperative cardiac risk is discussed separately. (See

"Evaluation of cardiac risk prior to noncardiac surgery", section on 'Assessing functional
status or exercise capacity'.)

Biomarkers — Plasma biomarkers (ie, brain natriuretic peptide [BNP], N-terminal pro-BNP
[NT-proBNP], troponin) may be used as part of preoperative risk assessment, particularly for
major adverse cardiac events [47]. This is discussed in detail separately. (See "Evaluation of
cardiac risk prior to noncardiac surgery", section on 'Laboratory testing'.)

Surgical risk — In general, emergency, intraperitoneal, intra-abdominal, intrathoracic, major

vascular, and open, longer procedures, and those associated with greater blood loss and
intraoperative fluid shifts, are associated with higher perioperative risk [25,29]. Laparoscopic,
endovascular, orthopedic, peripheral procedures, and breast surgery usually carry lower risks
[29].

However, there are broad variations of surgical risk within these categories. This concept was
illustrated by a study that used data from the American College of Surgeons National Surgical
Quality Improvement Program (ACS NSQIP) database to determine the risk of perioperative
adverse cardiac events (PACE), defined as cardiac arrest requiring cardiopulmonary
resuscitation or acute myocardial infarction, for three million operations that occurred between
2010 and 2015 [29]. There was a continuum of risk across over 1800 operations analyzed, and
significant differences in risk among operations within traditionally designated low,
intermediate, and high-risk categories. As an example, there was a threefold difference in risk
of PACE between laparoscopic total abdominal colectomy and Whipple procedure, both of which
are considered high risk according to the RCRI. This risk stratification model requires external
validation and may require institution-specific modification for application. Examples of the risk
of PACE for selected common operations as determined by this model are shown in a table
( table 5).

For several guidelines and perioperative risk assessment tools, surgical risk has been defined
according to risk of death or major adverse cardiac events, with high risk arbitrarily defined as
having a greater than 5 percent risk of major complications including mortality, intermediate
risk as 1 to 5 percent risk, and low risk as less than 1 percent risk [48]. The only well-established
very low-risk procedure is cataract extraction [49,50]. (See "Anesthesia for elective eye surgery",
section on 'Cataract surgery'.)

Surgical risk for specific postoperative outcomes (eg, cardiac complications versus pulmonary
complications) are not equivalent. More accurate assessment of surgical risk is best
accomplished by using computer- or web-based calculators of risk such as the ACS NSQIP
Surgical Risk Calculator to accurately define the procedural risk and to provide data-supported
risk assessment [29]. (See 'Risk assessment tools' below.)

Risk assessment tools — A number of tools have been developed that combine patient and
surgical factors to improve the accuracy of prediction of perioperative risk. The choice among
these tools may depend on institutional availability. For overall surgical risk assessment, the
authors prefer the ACS NSQIP Surgical Risk Calculator described below.

Assessment of overall risk or multiple outcomes

● The ACS NSQIP Surgical Risk Calculator is a free of charge online resource for risk
assessment that combines procedure-specific surgical risk with 20 patient factors [51]. The
tool calculates risks of 15 separate outcomes, which are displayed in graphic form, with
comparison to risk for an average patient. An example of a report generated by the ACS
NSQIP calculator is shown in a figure ( figure 2). Results can be easily understood by

practitioners and patients and may help with shared decision-making, especially regarding
specific risks that may be more meaningful to individual patients. For example, older
patients are typically less concerned about death than about a degradation of quality of life
or an inability to live independently [52]. Use of the results of the NSQIP calculator as part
of informed consent is discussed below. (See 'Informed consent and decision making'
below.)

The ACS NSQIP calculator is based on data from hospitals participating in NSQIP and has
not been widely validated externally. In addition, accuracy of risk estimates may be uneven
across outcome measures, and the calculator may be less useful for some categories of
procedures than others [53-56]. An advantage of this tool is that it is regularly updated
using machine learning. A disadvantage is that it can only be accessed through the
proprietary portal maintained by the ACS.

● A simple risk score has been developed for predicting 30-day mortality after noncardiac
surgery using data from the ACS NSQIP database [57]. Three elements, ASA PS status,
surgery risk, and whether the procedure is performed on an emergency basis, are scored
and assigned points. The scoring system and associated mortality are shown in a table
( table 6).

● A newly described automated machine learning model using only data in the electronic
health record identified patients at high risk of perioperative adverse outcomes [58]. In one
multi-institution study the model outperformed the ACS NSQIP calculator.

Assessment of specific outcomes

● Risk calculators specifically for cardiovascular complications include the Myocardial

Infarction or Cardiac Arrest (MICA) calculator (available online), and the RCRI ( table 7).
These tools and their use in evaluating preoperative cardiac risk are discussed separately.
(See "Evaluation of cardiac risk prior to noncardiac surgery", section on 'Using risk
assessment tools'.)

● The Society of Neuroscience in Anesthesiology and Critical Care published consensus

guidelines for risk assessment and reduction for perioperative stroke in noncardiac and
non-neurologic surgery [59]. (See "Perioperative stroke following noncardiac, noncarotid,
and nonneurologic surgery", section on 'Risk prediction tools'.)

● Risk calculators have been developed to estimate the risk of postoperative respiratory
failure or pneumonia. Some have used the ACS NSQIP data to create these [60,61]. (See

"Evaluation of perioperative pulmonary risk", section on 'Estimating postoperative

pulmonary risk'.)

CLINICAL EVALUATION

Medical history and review of systems — Clinicians who care for patients having anesthesia
need to have ready access to the patient’s medical information. The importance of complete
information was demonstrated in a single institution review of over 90,000 electronic records of
patients who had inpatient surgery [62]. Lack of documentation of existing comorbidities (eg,
chronic pain, diabetes, congestive heart failure) in the anesthesia preoperative evaluation was
associated with increased mortality and length of hospital stay.

● Medical and surgical history – The history should include the history of the present illness
and the planned procedure, past and current medical conditions, past surgical history, and
past experiences and problems with anesthesia or surgery in the patient or family members.

The patient should be asked about personal or family history of abnormal bleeding, which is
particularly important for procedures with a high risk of bleeding or severe harm should
bleeding occur (eg, neurosurgery, tonsillectomy, cardiac surgery). (See "Preoperative
assessment of bleeding risk" and 'Hematologic disorders' below.)

Personal or family history of thromboembolism is also important as it may impact the

perioperative management of antithrombotic therapy and the selection of venous
thromboembolism prophylaxis.

The patient’s allergies and medications should be confirmed, including over-the-counter,

complementary, herbal, and alternative medications and they should be asked about tobacco,
alcohol, and substance use, all of which may have implications for anesthesia and
perioperative care. (See "Perioperative medication management".)

The history should probe for the following issues related to anesthesia:

• Difficulty with airway management, severe postoperative nausea and vomiting, or a

personal or family history of malignant hyperthermia or pseudocholinesterase deficiency.

Conditions associated with difficulty with airway management appear in a table ( table 8).

• Excessive sore throat after anesthesia, dental injury related to anesthesia, or 'requiring a
small breathing tube' with previous anesthetics, which may indicate difficulty with airway
management.

If any of these issues are reported, records from previous anesthetics should be reviewed
when possible and may assist with planning for airway management.

● Review of systems – A review of organ systems may uncover symptoms that establish
previously undiagnosed conditions. A review of records, including notes from primary care
clinicians or specialists, and test results can reveal issues the patient may not recall.

Assessing functional capacity — All patients should be asked about their functional or
exercise capacity as part of the preoperative evaluation. Functional capacity reflects the
integrated responses of the pulmonary, cardiovascular, circulatory, neuromuscular, and
hematologic systems and muscle metabolism. Exercise capacity is an important determinant of
overall perioperative risk; patients with good exercise tolerance generally have low risk. (See
'Functional capacity' above.)

The assessment of functional status or exercise capacity can range from a self-reported ability
to engage in activities of daily living, to six-minute walk tests [63-65], to objective testing of
oxygen uptake with cardiopulmonary exercise testing (CPET) [45,66].

For assessment of functional status we use the Duke Activity Status Index (DASI), a
questionnaire that includes 12 measures of functional capacity ( table 9). The DASI provides a
more granular assessment of functional status than the commonly used subjective assessment,
whereby patients are asked to name the most strenuous activity they do regularly, or have done
most recently, and whether such activity causes chest pain, dyspnea, or claudication. More
formal assessment of functional capacity with the DASI may more reliably predict surgical risk
[41-43]. Preoperative assessment of functional status is discussed separately. (See "Evaluation
of cardiac risk prior to noncardiac surgery", section on 'Assessing functional status or exercise
capacity' and "Evaluation of perioperative pulmonary risk", section on 'Exercise testing'.)

Physical examination — The preoperative physical examination should be comprehensive,

including evaluation of major organ systems and should be based on symptoms, history, and
comorbidities. The examination performed by an anesthesia clinician prior to anesthesia is
typically more limited, and per the American Society of Anesthesiologists (ASA) guidelines,
focused on the airway, heart, and lungs.

Anesthesia directed physical examination — At a minimum, the preanesthetic examination

includes measurement of vital signs (blood pressure [BP], heart rate, ventilatory rate, and
oxygen saturation); height and weight with body mass index calculation; auscultation of the
heart and lungs (especially for irregular rhythms, murmurs, rales, or wheezing); basic
neurologic examinations; and an airway assessment ( table 10). (See "Airway management
for general anesthesia in adults", section on 'Airway assessment' and "Management of the
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anatomically difficult airway for general anesthesia in adults", section on 'Recognition of the
anatomically difficult airway'.)

● Blood pressure – The need to routinely measure BP in preoperative clinics has been
questioned. Guidelines in the United Kingdom suggest that preoperative clinics do not
need to measure BPs in patients being seen for elective procedures if they have
documented BPs <160/100 mmHg in the referral letter from primary care [67]. The
consensus among guidelines suggests that elective surgery in a hypertensive patient does
not need to be delayed if diastolic BP is <110 mmHg and systolic BP is <180 mmHg [67].
(See 'Cardiovascular disease' below.)

Patients often have anxiety-related elevated BPs during the preoperative visit even without
a history of hypertension. In this setting, the BP should be repeated, medical records
reviewed, or the patient asked about typical BP readings; if necessary, the patient can be
asked to measure the BP at home and report the results. Risk associated with hypertension
and preoperative management are discussed separately. (See 'Cardiovascular disease'
below and "Perioperative management of hypertension", section on 'Perioperative risks
associated with hypertension'.)

● Dentition – Patients should be assessed for loose, capped, damaged, missing, and artificial
teeth, which are at increased risk for damage during airway management. Abnormalities
should be documented and confirmed with the patient.

● Regional anesthesia site – If regional anesthesia (ie, neuraxial anesthesia/analgesia,

peripheral nerve block) is planned or possible, the regional anesthesia site should be
examined to assess for potential difficulty or infection, and any preexisting neuropathy or
weakness should be documented.

ASSESSMENT FOR CONDITIONS THAT INCREASE PERIOPERATIVE RISK

Patients with known or suspected medical conditions that are associated with increased
perioperative risk may require more extensive preoperative evaluation and/or testing. Some of
the conditions listed here will prompt intervention, though many will not. However, awareness
of these conditions is important to assess surgical risk and anticipate complications, which may
dictate postoperative care and monitoring.

Older age — Older adults, typically those 65 years and above, have a higher risk for
perioperative complications than younger patients, primarily as a result of comorbidities. Older
adults have increased mortality after surgery, particularly in those with frailty, dementia, or who
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undergo non-elective surgery [68]. Frailty is associated with up to five times greater risk of
complications, mortality, non-home discharge, and development of a new disability. [69,70].

Advanced age is an independent risk factor for postoperative pulmonary complications. This is
discussed separately. (See "Evaluation of perioperative pulmonary risk".)

A number of commonly employed and validated indices consider age as a minor component of
preoperative cardiac risk. (See "Evaluation of cardiac risk prior to noncardiac surgery".)

Assessment for aging related conditions that increase risk — A checklist for preoperative
assessment of older patients is shown in a table ( table 11). Older adults should be
assessed for the following:

● Frailty – All patients older than 65 years of age having major surgery should be screened
for frailty. We screen older adults with the FRAIL scale or the Clinical Frailty Scale
( figure 3). (See "Frailty", section on 'Rapid screening tools'.)

Frailty is a stronger predictor of morbidity and mortality than age. Frail patients are at
increased risk even for relatively minor, ambulatory procedures [71]. Heterogeneous
literature has suggested multimodal prehabilitation may benefit frail patients. At a
minimum, frailty assessment should be incorporated into the overall risk discussion with
patients since it may impact their decisions regarding surgery. (See "Anesthesia for the
older adult", section on 'Assessment for frailty'.)

● Cognitive dysfunction – Impaired cognition and dementia are common and are often
unrecognized in older adults [72]. These conditions are associated with postoperative
delirium and cognitive decline. We use a basic cognitive screening tool such as the Mini-Cog
(freely available on line) to screen patients preoperatively. We screen all patients 65
years and older and selectively evaluate younger patients who are impaired or have
significant risk factors.

Preoperative evaluation and interventions to reduce risk related to cognitive dysfunction

are not clearly identified at this time. However, preexisting cognitive impairment is a
signiﬁcant risk factor for perioperative neurocognitive disorders. As with frailty,
identification of cognitive dysfunction serves an important purpose in risk-benefit
discussions.

Perioperative neurocognitive dysfunction, including cognitive disorders and delirium, and

anesthetic management of patients with cognitive dysfunction are discussed separately.

(See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation

strategies".)

● History of falls – Patients who have fallen three or more times in the six months preceding
major surgery have a 100 percent chance of a perioperative complication [73].

● Dependency in activities of daily living – Patients who are dependent or partially

dependent on others to assist with bathing, feeding, and dressing have higher risks of
perioperative adverse events [44]. Nursing home residents are at particularly high risk of
death and further functional decline even with minor surgeries [74]. The inability to
independently perform activities of daily living is a factor in several risk prediction tools (eg,
the American College of Surgeons National Surgical Quality Improvement Program [ACS
NSQIP] surgical risk calculator).

Cardiovascular disease

● Hypertension – Hypertension is associated with an increased risk of perioperative

cardiovascular complications, but it is not clear that preoperative normalization of blood
pressure (BP) reduces perioperative risk. There is little evidence for an association between
perioperative complications and preoperative BP <180 mmHg systolic or 110 mmHg diastolic
[40,75]. (See "Perioperative management of hypertension", section on 'Perioperative risks
associated with hypertension' and "Anesthesia for patients with hypertension".)

The optimal BP level that should be achieved in anticipation of elective surgery is unclear. For
most patients, we agree with the Joint Guidelines from the Association of Anaesthetists of
Great Britain and Ireland and the British Hypertension Society on the preoperative
measurement and management of hypertension, which state that primary care practices
should aim to control BPs to <160/100 before referral for elective surgery, and surgery should
not be delayed if BPs are <180 mmHg systolic and 110 mmHg diastolic in the preoperative
clinic or on the day of surgery [40,67]. The 2024 American College of Cardiology/American
Heart Association (AHA/ACC) guideline on cardiac evaluation for noncardiac surgery
recommends that BP measurements on the day of surgery should not impact decision-
making, and that elevated BP >180/110 mmHg only impacts outcomes in patients with
revised cardiac risk index (RCRI) risk factors [40]. The decision to delay surgery for BP
optimization or institute new antihypertensive treatment must be individualized, based on
patient factors and the urgency of surgery [76]. Regardless of BP on the day of surgery, if
patients have taken their BP medications, are asymptomatic, and there is evidence that the
patient's BPs before the day of surgery are usually <160/100, then proceeding with planned
anesthesia is acceptable.

Most antihypertensive agents can be continued up to and including the day of surgery, with
the possible exception of angiotensin-converting enzyme (ACE) inhibitors and angiotensin II
receptor blockers (ARBs). ACE inhibitors and ARBs may increase the incidence of hypotension
during anesthesia. One author of this topic routinely continues these drugs, particularly for
patients with heart failure.

Whether to continue or stop ACE inhibitors or ARBs preoperatively is discussed in detail

separately.(See "Perioperative medication management", section on 'ACE inhibitors and
angiotensin II receptor blockers'.)

● Heart failure – Patients with heart failure (HF) have a significantly higher risk of
postoperative death than patients with coronary artery disease. Whenever possible, surgery
should be delayed in patients with decompensated HF. HF is an important risk factor in the
risk stratification models for preoperative assessment. (See 'Risk assessment tools' above.)

Decisions on whether and when to proceed with surgery, preoperative assessment, and
preoperative medical managementshould reflect the urgency of the surgery, the stability of
the patient's HF, and the possible therapeutic alternatives. Strategies for preoperative
assessment, decision making regarding the timing of surgery, and perioperative
management of patients with HF are discussed separately, and are shown in algorithms
( algorithm 1 and algorithm 2). (See "Perioperative management of heart failure in
patients undergoing noncardiac surgery".)

● Undiagnosed murmurs – Systolic murmurs may be the most common incidental finding
during a cardiac physical examination. The differential diagnoses include aortic stenosis or
sclerosis, mitral or tricuspid regurgitation, hypertrophic cardiomyopathy and hyperdynamic
states secondary to anemia, infection, fever, thyrotoxicosis, and pregnancy. Patients with
undiagnosed murmurs require a careful history. Any electrocardiogram (ECG) abnormalities,
symptoms of dyspnea, chest pain, syncope or near-syncope, or suspicion of valvular disease
in individuals >50 years of age warrant an echocardiogram. (See "Preoperative testing for
noncardiac surgery", section on 'Cardiac testing'.)

Diastolic murmurs are always pathologic and warrant further evaluation. Mitral stenosis (MS)
and aortic insufficiency are the most common causes with the former posing a significant
perioperative risk if more than mild. (See "Rheumatic mitral stenosis: Overview of
management", section on 'Management of noncardiac surgery'.)

● Valvular heart disease – Stenotic cardiac valvular diseases (ie, aortic stenosis [AS] and MS)
are associated with an increased risk of perioperative complications. Risks of anesthesia and
surgery can be minimized by an accurate diagnosis of type and severity of disease, planning
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the appropriate anesthetic, instituting a higher level of monitoring (such as an arterial line,
transesophageal echocardiography [TEE], or pulmonary artery catheter), changing venue for
the procedure (for example, not an ambulatory surgical center), and postoperative intensive
care [77]. Patients with known moderate or severe valvular disease should undergo
preoperative echocardiography if there has been no echocardiogram within one year, or if
there has been a significant change in physical examination or clinical status since the last
evaluation [78].

• AS is a common valvular lesion that increases in frequency with age and is associated with
coronary artery disease. The preoperative evaluation and risk assessment for patients with
AS, and indications for intervention, are discussed separately. (See "Noncardiac surgery in
adults with aortic stenosis".)

• Severe asymptomatic and untreated symptomatic MS are associated with high

perioperative risk. Preoperative evaluation and indications for intervention are discussed
separately. (See "Rheumatic mitral stenosis: Overview of management", section on
'Management of noncardiac surgery'.)

• Regurgitant valvular lesions (ie, aortic regurgitation [AR] or mitral regurgitation [MR]) are
typically better tolerated perioperatively than stenotic lesions. Preoperative risk assessment
and evaluation are discussed separately. (See "Noncardiac surgery in patients with mitral or
aortic regurgitation".)

• Patients with mechanical heart valves are usually maintained on anticoagulants. (See
"Overview of the management of patients with prosthetic heart valves".)

For most procedures, other than cataract surgery, these drugs are stopped preoperatively
based on the half-life of the drug to allow normalization of coagulation parameters.
Perioperative management of anticoagulants is discussed separately. (See "Perioperative
management of patients receiving anticoagulants".)

● Arrhythmias – The perioperative risk associated with some arrhythmias (eg, supraventricular
tachycardia, asymptomatic ventricular arrhythmias) is unclear [77]. However, some
arrhythmias, including symptomatic bradycardia, symptomatic ventricular arrhythmias,
Mobitz II, and third-degree heart block all increase perioperative risk [77], and may be
associated with underlying cardiac disease [79]. Patients with Mobitz II and complete heart
block need to have all except emergency surgery delayed for further evaluation and likely
pacemaker insertion. (See "The preoperative ECG: Evaluation and implications for anesthetic
management in adults".)

Clinically stable patients with atrial fibrillation (AF) are at elevated risk of perioperative
complications but generally do not require special evaluation or a change in medical
management unless there is a rapid ventricular rate. However, they may require modification
of anticoagulation. (See "Perioperative management of patients receiving anticoagulants",
section on 'Atrial fibrillation'.)

If AF is newly identified on a preoperative ECG or by physical examination, nonemergency

surgery is usually delayed for evaluation. If necessary, an urgent cardiology consultation can
be requested with a multidisciplinary discussion of the risks and benefits of proceeding with
surgery. It may be reasonable to proceed with minor procedures, such as cataract surgery or
colonoscopy, especially under monitored anesthesia care in patients with newly discovered
preoperative AF as long as the patient has a controlled rate (ie, less than 100 beats per
minute) and adequate BP. These patients require expedited referral for evaluation and
management of their AF. (See "Atrial fibrillation in patients undergoing noncardiac surgery",
section on 'Patients with newly discovered atrial fibrillation' and "Atrial fibrillation: Overview
and management of new-onset atrial fibrillation".)

● Coronary artery disease – Coronary artery disease (CAD) is a risk factor for perioperative
myocardial ischemia and infarction and death. CAD varies from a mild, stable disease with
little impact on perioperative outcome, to severe disease that accounts for serious
complications during anesthesia. A goal for preoperative evaluation is to identify a small
subset of patients who have unstable or severe CAD that will pose a significant risk with the
planned surgical procedure. Even patients with significant CAD have a low risk when having
low-risk surgeries [77,80].

Preoperative cardiac risk assessment, including evaluation for CAD, and management of
cardiac risk, are discussed separately. (See "Evaluation of cardiac risk prior to noncardiac
surgery" and "Management of cardiac risk for noncardiac surgery".)

Preoperative coronary revascularization (ie, coronary artery bypass grafting and/or

percutaneous coronary intervention) is discussed separately. (See "Management of cardiac
risk for noncardiac surgery", section on 'Revascularization before surgery'.)

● Cardiac implantable electronic devices – Patients with pacemakers and implantable

cardioverter defibrillators (ICDs) are often older adults, and may have HF, ischemic or valvular
disease, cardiomyopathies, or potentially lethal arrhythmias that increase perioperative risk.
Pacemakers and ICDs can be affected by intraoperative electrical interference; a systematic
approach to the perioperative evaluation and management of these devices is required and is

discussed separately. (See "Perioperative management of patients with a pacemaker or

implantable cardioverter-defibrillator".)

Cerebrovascular disease — Individuals with cerebrovascular disease are at increased risk of

cardiovascular and cerebrovascular events in the perioperative period [77,81]. The presence of
cerebrovascular disease is often a marker for coexisting cardiovascular disease [82], and a
stroke or transient ischemic attack (TIA) is a risk factor equivalent to known chronic coronary
syndrome, also referred to as stable ischemic heart disease, in the RCRI. (See 'Risk assessment
tools' above.)

The timing of surgery should be considered and elective surgery should be deferred in patients
with recent stroke [83,84]. The timing of surgery for patients with a history of stroke, the risk of
perioperative stroke, and management of asymptomatic carotid bruits are discussed separately.
(See "Perioperative stroke following noncardiac, noncarotid, and nonneurologic surgery",
section on 'Patient risk factors'.)

Neurologic disease — A number of neurologic diseases increase perioperative risk or require

specific perioperative evaluation and management. These issues are discussed separately. (See
"Perioperative care of the surgical patient with neurologic disease".)

Pulmonary disease — Postoperative pulmonary complications contribute significantly to

overall perioperative morbidity and mortality. In one large United States hospital database
study of patients who underwent bowel surgery, postoperative pulmonary complications were
associated with greater morbidity than postoperative cardiac complications [85]. Estimation of
pulmonary risk is a standard element of all preoperative medical evaluations. Preoperative
evaluation of pulmonary risk, including pulmonary function testing, the risks associated with
pulmonary hypertension, and strategies to prevent pulmonary complications, are discussed
separately. (See "Evaluation of perioperative pulmonary risk" and "Strategies to reduce
postoperative pulmonary complications in adults" and "Anesthesia for patients with chronic
obstructive pulmonary disease", section on 'Preanesthesia consultation'.)

Specialized testing, including cardiopulmonary exercise test and the six-minute walk test, are
discussed separately. (See "Evaluation of perioperative pulmonary risk", section on 'Exercise
testing' and "Overview of pulmonary function testing in adults", section on 'Six-minute walk
test'.)

Obstructive sleep apnea — Patients with obstructive sleep apnea (OSA) are at increased risk of
perioperative complications, including respiratory and cardiovascular complications, difficulty
with airway management, and postoperative delirium. The STOP-Bang questionnaire
( table 12) has been validated and used widely for preoperative screening for OSA, with
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scores of 3 or greater associated with increased risk of moderate to severe OSA and
postoperative complications. The authors use an alternative scoring model that includes any
two STOP criteria and either body mass index (BMI) >35 kg/m2 or male sex; this model is even
more predictive of OSA and does not require measurement of neck circumference [86]. Surgical
risk and preoperative evaluation and management of patients with OSA are discussed
separately. (See "Surgical risk and the preoperative evaluation and management of adults with
obstructive sleep apnea".)

Kidney disease — Chronic kidney disease (CKD) is associated with cardiovascular disease and
increases the risk of postoperative morbidity and mortality [87,88]. CKD is a factor in several risk
scores, including the RCRI and the Myocardial Infarction or Cardiac Arrest (MICA) cardiac risk
calculator. (See "Overview of the management of chronic kidney disease in adults", section on
'Association with cardiovascular disease, end-stage kidney disease, and mortality' and
"Evaluation of cardiac risk prior to noncardiac surgery", section on 'Using risk assessment
tools'.)

The strongest predictor of postoperative kidney dysfunction is preoperative kidney disease [89].
We measure creatinine preoperatively if CKD is known or suspected, the patient is >65 years of
age planning intermediate to high-risk surgery, or if the use of intravenous contrast dye is
planned. Serum electrolytes should also be measured in patients with CKD.

Patients with end-stage kidney disease on dialysis have a high incidence of other comorbidities
and are at increased risk of perioperative complications. Preanesthesia evaluation of patients
on dialysis is discussed separately. (See "Medical management of the dialysis patient
undergoing surgery".)

Liver disease — Severe liver disease increases perioperative risk, especially with major surgery.
Metabolic dysfunction-associated steatotic liver disease (MASLD), previously called nonalcoholic
fatty liver disease (NAFLD), affects 25 percent of the global population, is often asymptomatic,
and can lead to advanced liver fibrosis [90]. (See "Clinical features and diagnosis of metabolic
dysfunction-associated steatotic liver disease (nonalcoholic fatty liver disease) in adults", section
on 'Clinical features'.)

One author of this topic screens patients with risk factors for MASLD (eg, obesity, dyslipidemia,
type 2 diabetes) with the liver fibrosis-4 (FIB-4) tool as part of preoperative evaluation. An
elevated score on a FIB-4 screening tool which considers age, aspartate aminotransferase (AST),
alanine aminotransferase (ALT), and platelet count is associated with higher postoperative
mortality [91,92].

Preoperative evaluation, including preoperative laboratory evaluation, and assessment of

perioperative risk in patients with liver disease, are discussed separately. (See "Anesthesia for
the patient with liver disease", section on 'Preoperative evaluation for patients with known liver
disease' and "Assessing surgical risk in patients with liver disease", section on 'Screening for
liver disease before surgery'.)

Endocrine disease

● Diabetes – Diabetes mellitus is associated with increased risk of perioperative infection,

postoperative cardiovascular morbidity and mortality, and comorbidities that may affect
perioperative management. Preoperative assessment and perioperative management of
blood glucose in patients with diabetes mellitus are discussed separately. (See "Anesthesia for
patients with diabetes mellitus and/or hyperglycemia", section on 'Level of blood glucose
control' and "Perioperative management of blood glucose in adults with diabetes mellitus"
and "Overview of general medical care in nonpregnant adults with diabetes mellitus".)

Poorly controlled diabetes is associated with increased surgical site infections. Optimal blood
glucose targets have not been determined, but for some procedures (eg, joint replacement or
major spine surgeries) some surgeons have established absolute A1C cutoffs for performing
elective surgery (eg, <7.5 to 8 percent) [93]. (See "Susceptibility to infections in persons with
diabetes mellitus", section on 'Risk of infection'.)

● Thyroid disease – Significant hyper- or hypothyroidism may increase perioperative risk [94].
Preoperative evaluation and anesthetic management for patients with thyroid disease are
discussed separately. (See "Nonthyroid surgery in the patient with thyroid disease" and
"Anesthesia for patients with thyroid disease and for patients who undergo thyroid or
parathyroid surgery".)

● Adrenal disorders – Patients with Cushing’s disease and adrenal insufficiency require
management to lower perioperative risk. (See "Overview of the treatment of Cushing
syndrome" and "Treatment of adrenal insufficiency in adults", section on 'Surgery'.)

Patients with pheochromocytoma are at high risk of hemodynamic instability and

arrhythmias during surgery. Preoperative evaluation and preparation of these patients are
discussed separately. (See "Anesthesia for the adult with pheochromocytoma" and
"Anesthesia for the adult with pheochromocytoma", section on 'Preoperative evaluation'.)

Patients who have been taking glucocorticoid medication are at risk for adrenal insufficiency
in the perioperative period. Perioperative management of these patients is discussed
separately. (See "The management of the surgical patient taking glucocorticoids".)

● Pituitary abnormalities – Pituitary abnormalities can cause hormonal hyposecretion or

hypersecretion that may increase perioperative risk. As examples, both acromegaly and
Cushing’s syndrome increase the risk of difficulty with airway management [95] and are
associated with cardiovascular disease and OSA. (See "Epidemiology and clinical
manifestations of Cushing syndrome", section on 'Cardiovascular' and "Causes and clinical
manifestations of acromegaly", section on 'Cardiovascular disease' and "Causes and clinical
manifestations of acromegaly", section on 'Sleep apnea'.)

Hematologic disorders

● Anemia – Anemia is present in 5 to 7 percent of elective surgical patients, depending on

associated comorbidities and age [96]. Preoperative anemia, even when mild, is associated
with increased 30-day mortality after major noncardiac surgery [97-99], and also increases
the need for perioperative transfusions. This is discussed separately. (See "Perioperative
blood management: Strategies to minimize transfusions", section on 'Treatment of anemia
and iron deficiency' and "Indications and hemoglobin thresholds for RBC transfusion in
adults", section on 'Impact of anemia on morbidity and mortality'.)

When hemoglobin testing is indicated, it should be done early enough to allow time for
diagnosis and treatment of the causes of anemia or hemostatic abnormalities. Elective
surgery is best delayed to allow time to identify and potentially correct abnormalities
( algorithm 3). (See "Treatment of iron deficiency anemia in adults", section on
'Perioperative' and "Perioperative blood management: Strategies to minimize transfusions",
section on 'Preoperative strategies' and "Preoperative testing for noncardiac surgery".)

Patients with sickle cell disease are at risk of perioperative complications, some of which may
be ameliorated by modifications in management. Perioperative management of these
patients, including preoperative transfusion and control of acute pain, are discussed
separately. (See "Management of adults with sickle cell disease or thalassemia during cardiac
surgery", section on 'Sickle cell disease' and "Acute vaso-occlusive pain management in sickle
cell disease", section on 'Overview of acute pain management'.)

Perioperative concerns for patients with thalassemia, including anemia, skeletal

abnormalities, and possible cardiac or hepatic complications, are discussed separately. (See
"Management of adults with sickle cell disease or thalassemia during cardiac surgery",
section on 'Thalassemia'.)

● Bleeding risk – A careful personal and family history of bleeding is the foundation for
determining the risk of harmful bleeding with procedures [100]. The components of

preoperative determination of bleeding risk are discussed separately. (See "Preoperative

assessment of bleeding risk".)

● Venous thromboembolism (VTE) risk – VTE is a common postoperative complication, and

pulmonary embolism is one of the most common preventable causes of in-hospital deaths
following surgery. The risk of postoperative VTE should be assessed prior to surgery. Patients
at elevated risk of perioperative VTE include those with a history of previous VTE (particularly
recent VTE), cancer, obesity, inactivity, and having major lower extremity surgery. Risk
assessment and strategies for prevention are discussed separately. (See "Prevention of
venous thromboembolic disease in adult nonorthopedic surgical patients" and "Prevention of
venous thromboembolism in adults undergoing hip fracture repair or hip or knee
replacement" and "Overview of the causes of venous thrombosis in adults".)

Patients who are anticoagulated for AF, prosthetic heart valves, and/or recent or previous
thromboembolic events may require interruption of anticoagulation or perioperative bridging
strategies. Perioperative management of these patients is discussed separately. (See
"Perioperative management of patients receiving anticoagulants".)

Malnutrition — Malnutrition is a strong predictor of perioperative mortality and morbidity,

longer length of stay postoperatively, higher readmission rates, and increased costs of care
[101]. It is estimated that 50 percent or more of older adult patients having major surgery are
undernourished [102]. We screen patients for malnutrition and either send those who screen
positive for evaluation in a nutrition clinic or prescribe nutritional supplementation for several
weeks before surgery. Screening for malnutrition is discussed separately. (See "Geriatric
nutrition: Nutritional issues in older adults".)

Patients screened as nutritionally at risk before major surgery may benefit from preoperative
oral nutritional supplements with a minimum of 18 g protein two to three times per day for 7 to
14 days [103].

Obesity — With the exception of thromboembolism, obesity itself is not consistently associated
with an increased risk of major adverse outcomes and is not a factor in most commonly used
preoperative risk screening tools other than STOP-BANG [104-112].

However, obesity is associated with difficulty with airway management, positioning-related

peripheral nerve injuries, wound infection, and with a number of comorbidities that increase
perioperative risk, including OSA, heart disease, hypertension, and diabetes mellitus. (See
"Preanesthesia medical evaluation of the patient with obesity", section on 'Preoperative
evaluation'.)

Smoking — Exposure to tobacco, directly or through second-hand smoke, increases the risk of
postoperative pulmonary complications, wound complications, infections, neurologic
complications, and intensive care unit (ICU) admission. Those who smoke should be
encouraged to quit preoperatively; preoperative clinics play an important role in discussing the
benefits of smoking cessation and offering patients both pharmacologic and non-
pharmacologic interventions.

The perioperative risks of smoking and the benefits and optimal duration of preoperative
smoking cessation are discussed separately.

● (See "Evaluation of perioperative pulmonary risk", section on 'Smoking'.)

● (See "Strategies to reduce postoperative pulmonary complications in adults", section on

'Smoking cessation'.)

● (See "Smoking or vaping: Perioperative management", section on 'Perioperative risks of

smoking'.)

Alcohol misuse — Patients who misuse alcohol on a regular basis have an increased risk for
postoperative complications [113]. We screen all adults for alcohol use disorder with the Alcohol
Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire ( table 13). In two
studies of male United States veterans who had major surgery and who completed the AUDIT-C
questionnaire in the year prior to surgery, increasing AUDIT-C scores were associated with
increasing risk of postoperative complications [114] and longer length of stay, more ICU days,
and increased unplanned reoperation [115]. A similar study in male veterans who underwent
joint arthroplasty found similar results [116].

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 optimal period of cessation is
unknown, however at least four weeks of abstinence are required to reverse selected
physiologic abnormalities [113]. Most trials of alcohol cessation interventions have been
conducted in the nonoperative setting; a small trial in patients undergoing colorectal surgery
found reduced postoperative complications in patients randomly assigned to alcohol cessation
for one month prior to surgery [117].

PREOPERATIVE TESTING

Preoperative testing should be performed selectively, based on the patient's medical status, the
planned procedure, and the likelihood that test results will change management or help with

risk assessment ( table 14 and table 15). For most of the conditions discussed above, there
are no data to support routine preoperative testing or screening for the stage or stability of the
disease, particularly if the patient is asymptomatic or their disease is well controlled. There are
good data to suggest that preoperative tests increase costs and delay surgeries with no clear
improvement in outcomes. Thus, preoperative tests are best used only when a patient has new
or unstable symptoms, and when the surgery is not urgent or an emergency. Tests may also be
useful in higher-risk patients to aid shared decision making around the benefits of surgery, but
are not likely to improve outcomes. Preoperative testing is discussed separately. (See
"Preoperative testing for noncardiac surgery".)

POSTOPERATIVE PLANNING

When postoperative intensive care is indicated, arrangements for it are often initiated during
the preoperative evaluation session.

The plan for postoperative care is discussed in the UpToDate topics on anesthesia for specific
surgical procedures and for patients with specific comorbidities.

Breastfeeding patients — All women with children younger than two years of age should be
asked whether they are breastfeeding. Breastfeeding patients who will be separated from the
infant for more than a few hours should be encouraged to express and store breast milk
preoperatively for feeding the infant. There is no need to discard expressed breast milk after
anesthesia. There is no evidence of adverse effects from drugs used perioperatively on the
breastfed infant because the drugs are transferred to breast milk in only very small amounts.
However, there are limited or no data on the transfer of some anesthetic drugs to breast milk.
Further guidance and general principles of perioperative care in breastfeeding patients are
shown in a table ( table 16). For information on specific medications, consult the LactMed
database.

INFORMED CONSENT AND DECISION MAKING

Preoperative evaluation results in a risk assessment that should be part of shared decision-
making regarding the planned procedure and anesthetic care.

● Shared decision making – In our experience, most patients want to be made aware of
findings from their preoperative evaluation, be informed of risks, and be involved in decisions
about their care. The risks of surgery, the likelihood of the patient returning to baseline
functional status, and advance directives should be reviewed with all patients and are
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particularly important for older patients. The results of risk assessment tools can be used as
part of shared decision making and informed consent. In a single-center study that evaluated
sharing the results of the American College of Surgeons National Surgical Quality
Improvement Program (ACS NSQIP) calculator with patients, patient perceptions of the
experience were favorable; 93 percent of patients said the results improved their
understanding of their risks and 81 percent stated that they would want to know the details
of risk before consenting to surgery [118]. Overall, patients tended to overestimate their risks
of surgery, though high-risk patients tended to underestimate their risks. Knowledge of
personal risk decreased preoperative anxiety in 70 percent of patients and had no effect on
anxiety in 20 percent. The majority of patients were willing to undergo prehabilitation if it
would reduce their risks of complications.

● Consent for anesthesia – Informed consent must be obtained for anesthetic care and is
based on the principle of patient autonomy (ie, the patient's right to be involved in decisions
that affect them). In our experience, discussing options for upcoming anesthesia can lower
anxiety and improve patient satisfaction. Important components of patient preparation for
shared decisions regarding their anticipated anesthesia appear in a table ( table 17)
[119,120]. Patients should be informed of the more common risks and, when appropriate, of
complications that rarely occur after certain procedures but would have a major impact (eg,
postoperative visual loss associated with prone positioning for spine surgery). Complex
discussions ideally occur before the day of surgery, with adequate time to address all
questions.

The Association of Anaesthetists of Great Britain and Ireland has created guidelines for
consent for anesthesia [121], whereas the American Society of Anesthesiologists (ASA) has
not.

● Do not resuscitate and advanced directives – Patients with do not resuscitate (DNR) orders
should not be denied anesthesia and procedural care simply because of their DNR status
[122]. Whenever possible, the anesthesia clinician should involve the patient, family
members, and surrogates, as appropriate, in a detailed discussion of the patient's values and
preferences with respect to resuscitation. Some aspects of anesthesia care necessarily involve
procedures that in other circumstances would be considered resuscitation (eg, endotracheal
intubation). The patient's acceptance of specific procedures and levels of resuscitation (eg,
pharmacologic reversal of hypotension related to anesthetic medication) should be
determined and documented. The plan for postoperative reinstatement of any existing
directives should be determined and documented.

Informed consent for medical procedures is discussed in detail separately. (See "Informed
procedural consent".)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Preoperative medical
evaluation and risk assessment".)

SUMMARY AND RECOMMENDATIONS

● Timing of preoperative evaluation – Healthy patients having low-risk procedures can be

evaluated on the day of the procedure immediately before anesthesia. High-risk patients
(those who have conditions that increase perioperative risk) or those planning high-risk
procedures may require testing, time for medical interventions, and intensive planning, and
may therefore benefit from assessment well in advance of the procedure, depending on the
timing and intent of the procedure. (See 'Timing and logistics of preoperative evaluation'
above.)

● Components of evaluation – Preoperative evaluation should include clinical evaluation, risk

assessment, and assessment for and optimization of medical diseases that affect
perioperative risk. Preanesthesia evaluation should also include an anesthesia directed
physical examination, patient education and in some cases, informed consent for anesthesia,
and creation of a plan for anesthesia and postoperative care. (See 'Components of the
process' above.)

● Medical history and review of systems – Patients should be assessed with a medical history
and complete review of systems to assess for conditions that increase perioperative risk. The
history should include prior problems with anesthesia or surgery in the patient or family
members. (See 'Medical history and review of systems' above.)

● Physical examination – A comprehensive physical examination should be performed as part

of preoperative evaluation. The anesthesia-directed examination typically focuses on the
heart, lungs, and airway. (See 'Physical examination' above.)

● Assessment for conditions that increase perioperative risk – Patients with known or
suspected medical conditions that are associated with increased perioperative risk may
require more extensive preoperative evaluation and/or testing ( table 1 and table 15).

For example, older patients, patients with frailty, and those with significant cardiopulmonary
or pulmonary disease are at increased risk if undergoing intermediate or high-risk surgery.
These and other conditions associated with increased risk are discussed above. (See
'Assessment for conditions that increase perioperative risk' above.)

● Risk assessment – Assessment of the patient's risks of anesthesia and the planned
procedure informs the plan for anesthesia, may suggest the need for preoperative
intervention and perioperative care, and may affect shared decisions regarding surgical and
alternative options for treatment. (See 'Risk assessment' above.)

• Patients are assigned an American Society of Anesthesiologists Physical Status (ASA-PS)

class in anticipation of anesthesia ( figure 1). Patient factors, including comorbidities and
functional status, affect the patient's predicted risk. (See 'Patient risk factors for
perioperative morbidity and mortality' above.)

• Surgical procedures are classified as high, intermediate, or low risk of mortality or major
adverse events ( table 5). Cataract surgery is considered a very low-risk procedure. (See
'Surgical risk' above.)

• Risk assessment tools that include patient and surgical risk factors may be used to predict
perioperative risks of cardiac and pulmonary adverse events and perioperative mortality
( figure 2). (See 'Risk assessment tools' above.)

● Preoperative testing – Preoperative testing should be performed selectively, when needed

to estimate risk, or to address new or unstable symptoms or signs ( table 15 and
table 14). (See "Preoperative testing for noncardiac surgery".)

● Informed consent and decision-making – The risks of surgery and anesthesia, the
likelihood of the patient returning to baseline functional status, and advance directives
should be reviewed with all patients, to allow shared decision-making about options for care
( table 17). (See 'Informed consent and decision making' above.)

For patients with do not resuscitate (DNR) orders, the patient's acceptance of specific
procedures and levels of resuscitation should be determined and documented, including the
procedures necessary for anesthesia that would be considered resuscitation in other
circumstances.

Use of UpToDate is subject to the Terms of Use.

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88. Mathew A, Devereaux PJ, O'Hare A, et al. Chronic kidney disease and postoperative
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10/3/25, 10:08 p.m. UpToDate

Topic 94539 Version 38.0

GRAPHICS

Criteria and medical conditions for which preoperative evaluation is

recommended before the date of surgery

Medical condition Other criteria

General: Age:
Normal activity inhibited >65 years, unless surgery is minor (eg,
Monitoring or medical assistance at home cataract, cystoscopy) and under monitored
within two months anesthesia care
Hospital admission within two months Language:
Obesity (BMI >40 kg/m 2 ) Patient or parent/guardian cannot hear,
Frailty speak, or understand the language of
Malnourishment clinicians

Cardiovascular: Anesthesia related:

Coronary artery disease Patient has had previous difficult intubation,
Arrhythmias paralysis or nerve damage during anesthesia,
or patient or family has had previous elevated
Systolic blood pressure >160 mmHg or
temperature during anesthesia, is allergic to
diastolic blood pressure >100 mmHg
succinylcholine, has malignant hyperthermia
Heart failure
or pseudocholinesterase deficiency
Pulmonary:
Procedure related:
Asthma, severe
Intraoperative blood transfusion likely
COPD with symptoms
ICU admission likely
Exacerbation or progression of COPD or
High-risk surgery
asthma within two months
Previous airway surgery Pregnancy (for non-obstetric procedures):
Patient is pregnant (unless the procedure is
Unusual airway anatomy
termination)
Airway tumor or obstruction
Home ventilatory assistance or monitoring
OSA without PAP therapy

Endocrine:
Diabetes requiring insulin therapy
Adrenal disorders
Active thyroid disease

Central nervous system/Neuromuscular:

Seizure disorder
CNS disease (eg, multiple sclerosis)
Myopathy or other muscle disorders

Hepatic:

Active hepatobiliary disease or compromise

Renal:
Renal insufficiency or failure

Hematologic:
Anemia
Thrombocytopenia
Bleeding disorder
Anticoagulant therapy

Musculoskeletal:
Kyphosis or scoliosis compromising function
Temporomandibular joint disorder limiting
mouth opening
Cervical or thoracic spine injury/disease

Oncology:
Chemo- or radiotherapy within last two
months
Significant physiologic compromise from
disease or treatment

This table shows medical conditions and other patient criteria for preanesthesia evaluation before the
day of surgery. For further information, refer to UpToDate content on preanesthesia evaluation for
noncardiac surgery.

BMI: body mass index; CNS: central nervous system; COPD: chronic obstructive pulmonary disease; ICU:
intensive care unit; OSA: obstructive sleep apnea; PAP: positive airway pressure.

Graphic 114155 Version 5.0

Sample preoperative medical screening questionnaire

1. Age

2. Weight

3. Height

4. Allergies

5. Current medications

6. Prior surgeries

7. Have you recently had a respiratory infection, such as a cold, flu, or COVID-19?
If COVID-19, when was the date of your diagnosis?

8. Do you have chest pain?

9. Do you have a heart condition?

If yes: Please explain.

10. Do you have hypertension (high blood pressure)?

11. Do you experience shortness of breath?

12. Do you have asthma, bronchitis, chronic obstructive pulmonary disease (COPD) or any other
breathing problem?

13. Do you have obstructive sleep apnea (OSA)?

14. Do you currently smoke, or have you ever smoked, cigarettes?

If yes: Packs per day, number of years smoked, date you quit smoking.

15. Do you consume alcohol?

If yes, how many drinks per week?

16. Do you now use, or have you used, recreational drugs?

If so, what type of drug?

17. Have you taken cortisone (steroids) in the last 6 months?

18. Do you take aspirin or any nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen, or
naproxen?

19. Do you take any herbal supplements, complementary or alternative medicines, or vitamins?
If yes, which ones and how recently?

20. Do you have diabetes? Do you take any medications to treat your diabetes?

21. Have you had hepatitis, liver disease, or jaundice?

22. Do you have a thyroid condition?

23. Do you have, or have you ever had, kidney disease?

24. Do you have ulcers, gastroesophageal reflux (GERD or heartburn), or other stomach disorders?

25. Do you have back or neck pain?

26. Do you have any muscle or nerve disease?

27. Do you or any of your family have sickle cell disease or trait?

28. Have you or any blood relatives had difficulties with anesthesia other than nausea and vomiting?
If yes: Please explain.

29. Do you have a bleeding disorder?

30. Do you have any loose, chipped, or false teeth? Bridgework? Oral piercings?

31. Have you ever received a blood transfusion?

32. Females: Are you pregnant?

If yes, due date:

Adapted with permission from: Pre-anesthesia questionnaire. American Association of Nurse Anesthesiology.
www.aana.com/patients/pre-anesthesia-questionnaire (Accessed on January 28, 2022). Copyright © 2022 American Association of
Nurse Anesthesiology.

Graphic 66690 Version 3.0

Patient preoperative history

Name: DOB: Preferred daytime phone #:

Planned surgery: Today's date:

Surgeon:

Primary care physician: PCP phone #:

Please list all previous surgeries (and approximate dates)

Please list any allergies to medications, latex, food, or other (and your reactions to them)

List all medications (include over-the-counter drugs, inhalers, herbals, supplements, and aspirin)

Drug name Dose and how often? Drug name Dose and how often?

1. 7.

2. 8.

3. 9.

4. 10.

5. 11.

6. 12.

Weight: (lbs or kg) ____

Height: (inches or cm) ____
(Circle the measurement units you use)

Please check any of the following that apply to your health:

Heart attack at any time Congenital heart disease

Heart attack within past 60 days Hypertension

Chest pain or pressure with activity Murmur

Angina Valve disorder

Heart failure LVAD

Heart surgery Heart device

Heart stent in the last 6 months Pacemaker

Unable to climb 2 flights of stairs or walking 2 Defibrillator

blocks because of chest pain or trouble
breathing

Heart stent at any time Fainted in the last year

Atrial fibrillation Pain in legs while walking

Arrhythmia None of these

Oxygen at home COPD

Pulmonary hypertension Pneumonia in last 2 months

Trouble breathing at rest or with minimal Any problems with your lungs
exertions

Asthma Severe cough

None of these

Face, arm, or leg weakness Myasthenia gravis

Stroke/TIA within past 60 days Muscular dystrophy

Stroke or TIA at any time Spinal cord injury

Paralysis Brain tumor

Difficulty speaking Brain aneurysm or AVM

Dementia Epilepsy, blackouts, or seizures

Parkinson disease None of these

Hospitalized in last 30 days Hypothyroidism

Anemia Adrenal disorder

Sickle cell disease Pituitary disorder

Blood transfusion in last 3 months Dialysis

Blood clots/pulmonary embolus Lupus

Diabetes Rheumatoid arthritis

Cancer: What type? ________ Scleroderma

Chemo or radiation last 3 months Sjögren's disease

Kidney disease other than stones Jehovah's Witness

Liver disease Use illegal drugs (excluding marijuana)

Cirrhosis Kidney failure

Hepatitis B/C Taking antibiotics for any reason

Jaundice HIV

Hyperthyroidism None of these

Blood thinners or anticoagulants other than Von Willebrands

aspirin

Bleeding with surgery or tooth extractions Known bleeding disorder

Hemophilia Severe nose bleeds

None of these

Malignant hyperthermia (in blood relatives or Dentures

self) with anesthesia

Severe nausea or vomiting from anesthesia Problems opening your mouth

Difficult airway with anesthesia Loose teeth

None of these

Unintentional weight loss >10 lbs Difficulty doing your own shopping

Difficulty getting out of bed/chair by yourself Feel that everything you did was an effort: ____
days in the last week

Difficulty making your own meals Need assistance with eating or bathing or
dressing

Your physical abilities limit your daily activities Fallen in the last 6 months ( ____ times)

None of these

Very loud snoring High blood pressure/hypertension

Tired/fall asleep frequently during the day Sleep apnea; NO CPAP

Observed to stop breathing during sleep Sleep apnea; use CPAP

None of these

Cannot speak and/or understand English Deaf

Cannot lie flat for 45 minutes Blind

Currently pregnant. Last menstrual period began: ________

Smoker (current or past) ____ packs/day for ____ years. Quit date: ________

Drink alcohol. How much each day? ____ beers ____ glasses of wine ____ shots of hard alcohol

None of these

Please list any medical illness or medications not noted already:

The graphic shows an example of a form that would be used to start a medical history during evaluation
in anticipation of anesthesia. In this example, conditions shown in bold type would prompt an in-person
preoperative evaluation. For further information, refer to UpToDate content on preoperative evaluation
for noncardiac surgery.

AVM: arteriovenous malformation; COPD: chronic obstructive pulmonary disease; CPAP: continuous
positive airway pressure; DOB: date of birth; PCP: primary care physician; TIA: transient ischemic attack.

Graphic 114154 Version 4.0

American Society of Anesthesiologists Physical Status (ASA PS) Classification

System

Pediatric
Adult examples, Obstetric examples,
ASA PS examples,
Definition including but including but not
classification including but
not limited to: limited to:
not limited to:

ASA I A normal Healthy, non- Healthy (no acute

healthy smoking, no or or chronic
patient minimal alcohol disease), normal
use. BMI percentile
for age.

ASA II A patient Mild diseases only Asymptomatic Normal pregnancy * , well

with mild without substantive congenital controlled gestational HTN,
systemic functional cardiac disease, controlled preeclampsia
disease limitations. Current well controlled without severe features,
smoker, social dysrhythmias, diet-controlled gestational
alcohol drinker, asthma without DM.
pregnancy, obesity exacerbation,
(30<BMI<40), well- well controlled
controlled DM/HTN, epilepsy, non-
mild lung disease. insulin
dependent
diabetes mellitus,
abnormal BMI
percentile for
age,
mild/moderate
OSA, oncologic
state in
remission, autism
with mild
limitations.

ASA III A patient Substantive Uncorrected Preeclampsia with severe

with severe functional stable congenital features, gestational DM
systemic limitations; One or cardiac with complications or high
disease more moderate to abnormality, insulin requirements, a
severe diseases. asthma with thrombophilic disease
Poorly controlled exacerbation, requiring anticoagulation.
DM or HTN, COPD, poorly controlled
morbid obesity (BMI epilepsy, insulin
≥40), active dependent
hepatitis, alcohol diabetes mellitus,

dependence or morbid obesity,

abuse, implanted malnutrition,
pacemaker, severe OSA,
moderate reduction oncologic state,
of ejection fraction, renal failure,
ESRD undergoing muscular
regularly scheduled dystrophy, cystic
dialysis, history (>3 fibrosis, history
months) of MI, CVA, of organ
TIA, or CAD/stents. transplantation,
brain/spinal cord
malformation,
symptomatic
hydrocephalus,
premature infant
PCA <60 weeks,
autism with
severe
limitations,
metabolic
disease, difficult
airway, long term
parenteral
nutrition. Full
term infants <6
weeks of age.

ASA IV A patient Recent (<3 months) Symptomatic Preeclampsia with severe

with severe MI, CVA, TIA or congenital features complicated by
systemic CAD/stents, cardiac HELLP or other adverse
disease that ongoing cardiac abnormality, event, peripartum
is a ischemia or severe congestive heart cardiomyopathy with EF <40
constant valve dysfunction, failure, active uncorrected/decompensated
threat to life severe reduction of sequelae of heart disease, acquired or
ejection fraction, prematurity, congenital.
shock, sepsis, DIC, acute hypoxic-
ARD or ESRD not ischemic
undergoing encephalopathy,
regularly scheduled shock, sepsis,
dialysis. disseminated
intravascular
coagulation,
automatic
implantable
cardioverter-
defibrillator,
ventilator
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dependence,
endocrinopathy,
severe trauma,
severe
respiratory
distress,
advanced
oncologic state.

ASA V A moribund Ruptured Massive trauma, Uterine rupture.

patient who abdominal/thoracic intracranial
is not aneurysm, massive hemorrhage with
expected to trauma, intracranial mass effect,
survive bleed with mass patient requiring
without the effect, ischemic ECMO,
operation bowel in the face of respiratory
significant cardiac failure or arrest,
pathology or malignant
multiple hypertension,
organ/system decompensated
dysfunction. congestive heart
failure, hepatic
encephalopathy,
ischemic bowel
or multiple
organ/system
dysfunction.

ASA VI A declared
brain-dead
patient
whose
organs are
being
removed for
donor
purposes

The addition of "E" to the numerical status (eg, IE, IIE, etc) denotes Emergency surgery (an emergency is
defined as existing when delay in treatment of the patient would lead to a significant increase in the
threat to life or body part).

ARDS: acute respiratory distress syndrome; BMI: body mass index; CAD: coronary artery disease; COPD:
chronic obstructive pulmonary disease; CVA: cerebrovascular accident; DIC: disseminated intravascular
coagulation; DM: diabetes mellitus; HTN: hypertension; ESKD: end-stage kidney disease; MI: myocardial
infarction; PCA: post conceptual age; TIA: transient ischemic attack.

* Although pregnancy is not a disease, the parturient's physiologic state is significantly altered from
when the woman is not pregnant, hence the assignment of ASA 2 for a woman with uncomplicated
pregnancy.

ASA Physical Status Classification System (Copyright © 2020) is reprinted with permission of the American Society of
Anesthesiologists, 1061 American Lane, Schaumburg, Illinois 60173-4973.

Graphic 87504 Version 10.0

Mortality versus ASA classification and procedure risk

The observed mortality rate as a function of American Society of Anesthesiologists' physical status and
surgery-specific risk.

ASA: American Society of Anesthesiologists.

From: Glance L, Lustik SJ, Hannan EL, et al. The surgical mortality probability model derivation and validation of a simple risk
prediction rule for noncardiac surgery. Ann Surg 2012; 255:696. DOI: 10.1097/SLA.0b013e31824b45af. Copyright © 2012.
Reproduced with permission from Lippincott Williams & Wilkins. Unauthorized reproduction of this material is prohibited.

Graphic 113974 Version 3.0

Selected examples of low, intermediate, and high intrinsic cardiac risk

operations

Estimated
cardiac risk of
Description Odds ratio* (95% CI)
hypothetical
patient ¶ (%)

Low intrinsic cardiac risk

Partial mastectomy (lumpectomy) 0.22 (0.15-0.31) 0.05

Arthroscopic rotator cuff repair 0.32 (0.19-0.54) 0.07

Simple mastectomy (complete breast) 0.37 (0.26-0.50) 0.08

Laparoscopic appendectomy 0.45 (0.33-0.62) 0.10

Laparoscopic cholecystectomy 0.62 (0.53-0.72) 0.14

Intermediate intrinsic cardiac risk

Transurethral resection of bladder tumor, large 0.85 (0.61-1.20) 0.19

Laparoscopic prostatectomy 0.88 (0.69-1.12) 0.19

Open appendectomy 0.95 (0.51-1.75) 0.21

Total hip arthroplasty 0.95 (0.83-1.08) 0.21

Laparoscopic radial hysterectomy with bilateral 1.05 (0.57-1.94) 0.23

salpingo-oophorectomy

High intrinsic cardiac risk

Laparoscopic total abdominal colectomy with 1.50 (0.92-2.44) 0.33

ileostomy

Breast reconstruction with free flap 1.52 (0.81-2.86) 0.33

Open cholecystectomy 1.55 (1.25-1.92) 0.34

Open ventral hernia repair, incarcerated or 1.78 (1.29-2.44) 0.39

strangulated, recurrent

Whipple procedure, pylorus-sparing 4.70 (4.00-5.53) 1.02

ASA: American Society of Anesthesiologists.

* Odds ratios are relative to the statistically estimated average procedure. Values greater than 1.0
represent higher than average risk for perioperative adverse cardiac events, whereas values less than 1.0
represent lower than average risk for perioperative adverse cardiac events.

¶ The hypothetical patient used to estimate numerical risk values across all operations for comparison
was a 67-year-old White female with hypertension, diabetes requiring oral therapy, and a body mass

index of 32 (class I obesity), who is functionally independent, does not smoke, and is of ASA physical class
II.

From: Liu JB, Liu Y, Cohen ME, et al. Defining the intrinsic cardiac risks of operations to improve preoperative cardiac risk
assessments. Anesthesiology 2018; 128:283. DOI: 10.1097/ALN.0000000000002024. Copyright © 2018 American Society of
Anesthesiologists. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is
prohibited.

Graphic 116645 Version 4.0

ACS NSQIP surgical risk calculator report

This graphic shows an example of the type of report that would be generated after entering patient data
into the ACS NSQIP calculator, based on a fictitious patient. The actual report would reflect the individual
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patient data.

ACS: American College of Surgeons; NSQIP: National Surgical Quality Improvement Program.

Reproduced with permission from the American College of Surgeons National Surgical Quality Improvement Program. Copyright
© 2007 - 2016. All rights reserved.

Graphic 113975 Version 2.0

Surgical mortality probability model for predicting risk of 30-day mortality afte
noncardiac surgery

Risk factor Points assigned

ASA physical status

I 0

II 2

III 4

IV 5

V 6

Procedure risk

Low risk 0

Intermediate risk 1

High risk 2

Emergency

Non-emergency 0

Emergency surgery 1

Class Point total Mortality

I 0 to 4 <0.50%

II 5 to 6 1.5 to 4.0%

III 7 to 9 >10%

Graphic 113976 Version 4.0

Risk factors for revised cardiac risk index

High risk surgery (intraperitoneal, intrathoracic, or suprainguinal vascular procedures)

Ischemic heart disease (by any diagnostic criteria)

Heart failure

Cerebrovascular disease

Diabetes mellitus requiring insulin

Creatinine ≥2.0 mg/dL

Adapted from: 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.

Graphic 114577 Version 1.0

Patient history for airway assessment

1. Previous airway management documentation

Check anesthesia records for previous difficulties and ask patients whether they are aware of any
anesthetic problems

2. Conditions associated with airway difficulties

History of difficult airway

History of aspiration pneumonia after intubation

History of dental or oral trauma following intubation

Head and neck irradiation

Head and neck surgery

Cervical spine disease

Cervical spine surgery

Obstructive sleep apnea

Acromegaly

Rheumatoid arthritis

Ankylosing spondylitis

Marfan's syndrome

Pierre-Robin syndrome

Klippel-Feil abnormalities of the cervical spine

Significant sore throat after anesthesia

Previous airway injury during anesthesia

Patient reporting need for a "small tube"

Head, neck, and oropharyngeal

Tumors

Infections

Hematomas

Trauma

Cystic hygroma

Spinal muscular atrophy

Graphic 114346 Version 2.0

Duke Activity Status Index questionnaire to determine functional capacity [1]

Activity Weight

Can you...

1. Take care of yourself, that is, eating, dressing, bathing or using the toilet? 2.75

2. Walk indoors, such as around your house? 1.75

3. Walk a block or 2 on level ground? 2.75

4. Climb a flight of stairs or walk up a hill? 5.50

5. Run a short distance? 8.00

6. Do light work around the house like dusting or washing dishes? 2.70

7. Do moderate work around the house like vacuuming, sweeping floors, or carrying in 3.50
groceries?

8. Do heavy work around the house like scrubbing floors, or lifting or moving heavy 8.00
furniture?

9. Do yardwork like raking leaves, weeding or pushing a power mower? 4.50

10. Have sexual relations? 5.25

11. Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, 6.00
or throwing a baseball or football?

12. Participate in strenuous sports like swimming, singles tennis, football, basketball or 7.50
skiing?

Total DASI score: ______

METs [(DASI score × 0.43) + 9.6] / 3.5: ______

The higher the DASI score, the more physically active the patient is. Patients who can achieve <4 METs
have poor functional capacity, 4 to 10 METs suggest moderate functional capacity, and >10 METs suggest
excellent functional capacity. The DASI questionnaire is not designed to assess very high levels of physical
activity. The maximum DASI score is 58.2, which would be the equivalent of 9.89 METs.

DASI: Duke Activity Status Index; METs: metabolic equivalents.

Reference:
1. Hlatky MA, Boineau RE, Higginbotham MB, et al. A brief self-administered questionnaire to determine functional capacity
(the Duke Activity Status Index). Am J Cardiol 1989; 64:651.

Graphic 121071 Version 6.0

Components of the preoperative airway physical examination

Airway examination component Nonreassuring findings

Length of upper incisors Relatively long

Relationship of maxillary and mandibular incisors Prominent "overbite" (maxillary incisors anterior to
during normal jaw closure mandibular incisors)

Relationship of maxillary and mandibular incisors Patient cannot bring mandibular incisors anterior to
during voluntary protrusion of mandible* (in front of) maxillary incisors

Interincisor distance Less than 3 cm

Visibility of uvula Not visible when tongue is protruded with patient

in sitting position (eg, Mallampati class >2)

Shape of palate Highly arched or very narrow

Compliance of mandibular space Stiff, indurated, occupied by mass, or non-resilient

Thyromental distance Less than three ordinary finger-breadths

Length of neck Short

Thickness of neck Thick

Range of motion of head and neck Patient cannot touch tip of chin to chest or cannot
extend neck

This table displays some findings of the airway physical examination that may suggest the presence of a
difficult intubation. The decision to examine some or all of the airway components shown on this table
depends on the clinical context and judgment of the practitioner. The table is not intended as a
mandatory or exhaustive list of the components of an airway examination. The order of presentation in
this table follows the "line of sight" that occurs during conventional oral laryngoscopy.

* A more objective measurement related too mandibular protrusion is the upper lip bite test, which
assesses the patient's ability to reach and cover the upper lip with their lower incisors. Grading for the
upper lip bite test is as follows:
Grade 1: The patient can fully cover the upper lip with lower incisors
Grade 2: The patient can partially cover the upper lip with lower incisors
Grade 3: The patient cannot reach the upper lip with lower teeth

From: Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult airway: an updated report
by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013; 118:251.
DOI: 10.1097/ALN.0b013e31827773b2. Copyright © 2013 American Society of Anesthesiologists. Reproduced with permission from
Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited.

Graphic 108981 Version 12.0

Checklist for the optimal preoperative assessment of the geriatric surgical

patient

In addition to conducting a complete history and physical examination of the patient,

the following assessments are strongly recommended:

Assess the patient's cognitive ability and capacity to understand the anticipated surgery.

Screen the patient for depression.

Identify the patient's risk factors for developing postoperative delirium.

Document history of falls.

Determine baseline frailty score.

Assess patient's nutritional status and consider preoperative interventions if the patient is at
severe nutritional risk.

Monitor for polypharmacy.

Determine the patient's treatment goals and expectations in the context of the possible treatment
outcomes.

Determine patient's family and social support system.

Order appropriate preoperative diagnostic tests focused on older patients.

Original figure modified for this publication. From: Chow WB, Rosenthal RA, Merkow RP, et al. Optimal preoperative assessment of
the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality
Improvement Program and the American Geriatrics Society. J Am Coll Surg 2012; 215:453. Table used with the permission of
Elsevier, Inc. All rights reserved.

Graphic 114173 Version 4.0

Clinical Frailty Scale

IADLs: instrumental activities of daily living.

Reproduced with permission from: Dalhousie University. Clinical Frailty Scale. Available at: https://www.dal.ca/sites/gmr/our-
tools/clinical-frailty-scale.html (Accessed on October 20, 2020). Copyright © 2020 Rockwood K, et al.

Graphic 129047 Version 1.0

Algorithm for patients with a heart failure syndrome with an indication for
urgent noncardiac surgery

ACS: acute coronary syndrome; HF: heart failure; MACE: major adverse cardiac events; BNP: B-type
natriuretic peptide; NT-proBNP: N-terminal pro-BNP.

* Refer to UpToDate content on management of ACS.

¶ Assessment of the HF syndrome includes clinical evaluation with selective use of preoperative tests
based upon the likelihood of testing changing management. While we do not recommend routine
preoperative measurement of BNP or NT-proBNP levels, measurement of BNP or NT-proBNP is helpful in
patients with suspected HF when the diagnosis is uncertain and may also be helpful in patients with HF
when disease stability is uncertain. During treatment with sacubitril-valsartan, plasma NT-proBNP levels
(but not plasma BNP levels) can be used to assess HF.

Δ Stable HF syndromes include stable HF as well as asymptomatic left ventricular dysfunction.

◊ Refer to UpToDate content on management of heart failure with reduced ejection fraction, heart
failure with preserved ejection fraction, heart failure with mid-range ejection fraction, and refractory
heart failure.

Graphic 105827 Version 3.0

Algorithm for patients with a heart failure syndrome with an indication for
elective noncardiac surgery

ACS: acute coronary syndrome; HF: heart failure; MACE: major adverse cardiac events; BNP: B-type
natriuretic peptide; NT-proBNP: N-terminal pro-BNP.

* Refer to UpToDate content on management of ACS.

¶ Assessment of the HF syndrome includes clinical evaluation with selective use of preoperative tests
based upon the likelihood of testing changing management. While we do not recommend routine
preoperative measurement of BNP or NT-proBNP levels, measurement of BNP or NT-proBNP is helpful in
patients with suspected HF when the diagnosis is uncertain and may also be helpful in patients with HF
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when disease stability is uncertain. During treatment with sacubitril-valsartan, plasma NT-proBNP levels
(but not plasma BNP levels) can be used to assess HF.

Δ Stable HF syndromes include stable HF as well as asymptomatic left ventricular dysfunction.

◊ Refer to UpToDate content on management of refractory heart failure.

Graphic 105828 Version 2.0

STOP-Bang questionnaire

Yes No Snoring?

Do you snore loudly (loud enough to be heard through closed doors, or your bed
partner elbows you for snoring at night)?

Yes No Tired?

Do you often feel tired, fatigued, or sleepy during the daytime (such as falling
asleep during driving)?

Yes No Observed?

Has anyone observed you stop breathing or choking/gasping during your sleep?

Yes No Pressure?

Do you have or are you being treated for high blood pressure?

Yes No Body mass index more than 35 kg/m 2 ?

Yes No Age older than 50 years old?

Yes No Neck size large (measured around Adam's apple)?

Is your shirt collar 16 inches or larger?

Yes No Gender (biologic sex) = Male?

Scoring criteria:

Low risk of OSA: Yes to 0 to 2 questions

Intermediate risk of OSA: Yes to 3 to 4 questions

High risk of OSA: Yes to 5 to 8 questions

OSA: obstructive sleep apnea.

References:
1. Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea.
Anesthesiology 2008; 108:812.
2. Chung F, Subramanyam R, Liao P, et al. High STOP-Bang score indicates a high probability of obstructive sleep apnoea. Br J
Anaesth 2012; 108:768.

Graphic 87572 Version 11.0

Algorithm for the management of preoperative anemia

This algorithm is intended to help clinicians determine whether surgery should be delayed for
preoperative anemia. Testing for preoperative anemia is a key means of avoiding unnecessary
transfusions. In many cases, a cause such as iron deficiency can be identified and treated. Clinical
judgment is required to assess the urgency of surgery and the benefits of delaying surgery. For example,
it may not be necessary to postpone minor procedures, such as cataract surgery. Anemia should always
be evaluated for the underlying cause so that appropriate treatment can be determined.

When iron is administered, sufficient time should be allowed for correction before elective surgery
(typically two to four weeks for partial correction and six to eight weeks for full correction). Intravenous
(IV) iron at least 10 days before surgery is an option if semi-elective cardiac surgery is scheduled in less
than four to six weeks, and for patients who cannot tolerate oral iron or do not have a response (eg, due
to poor absorption). Patients with an indication erythropoietin (EPO) prior to cardiac surgery typically are
treated with an EPO-stimulating agent (eg, epoetin alfa 600 units/kg weekly, or 300 units/kg daily)
starting three weeks (or as short as 10 days) prior to the procedure.

Refer to UpToDate for the approach to the anemia evaluation and for treatment of specific causes of
anemia.

AIHA: autoimmune hemolytic anemia; MDS: myelodysplastic syndrome.

* Refer to UpToDate for details of the indications for preoperative screening for anemia.

¶ Refer to UpToDate for indications for transfusion. Transfusion is reserved for the treatment of severe or
symptomatic anemia or if there is ongoing significant blood loss that would cause severe or symptomatic
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anemia. Tolerance of anemia depends on the patient population. Transfusion is a short-term therapy that
does not address or treat the underlying cause of anemia.

Δ Refer to UpToDate for the evidence for efficacy and safety of erythropoietin in various patient
populations.

Graphic 120496 Version 4.0

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)

• 2 to 4 times a month (2 points)

• 2 to 3 times per week (3 points)

• 4 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?

• 1 or 2 (0 points)

• 3 or 4 (1 point)

• 5 or 6 (2 points)

• 7 to 9 (3 points)

• 10 or more (4 points)

Question #3: How often did you have 6 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 0 to 12 (scores of 0 reflect no 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 5.0

Recommendations for patient-specific baseline testing before anesthesia *

Procedure/patient type Test

Injection of contrast dye Creatinine ¶

Potential for significant blood loss Hemoglobin/hematocrit ¶

Likelihood of transfusion requirement Type and screen

Possibility of pregnancy Pregnancy test Δ

End-stage kidney disease Potassium level ◊

Diabetes Glucose concentration on the day of surgery ◊

For further information, refer to UpToDate content on preanesthesia evaluation for noncardiac surgery.

* For testing recommendations for disease evaluation refer to UpToDate graphic on diagnostic testing
for patients anticipating anesthesia.

¶ Results from laboratory tests within three months of surgery are acceptable unless major
abnormalities are present or the patient's condition has changed.

Δ Pregnancy testing is not recommended before the day of surgery unless pregnancy is suspected.

◊ No absolute level of either potassium or glucose has been determined to preclude surgery and
anesthesia. The benefits of the procedure must be balanced against the risk of proceeding in a patient
with abnormal results.

Graphic 114163 Version 3.0

Diagnostic testing that may be considered for patients anticipating anesthesia

and procedures, for suspected but undiagnosed diseases, or progressive or
unstable conditions

Condition Tests to consider for evaluation

Age >65 Creatinine, hemoglobin

Alcohol use disorder ECG, electrolytes, hemoglobin, LFTs, platelet count, PT/INR

Anasarca Albumin, BUN, creatinine, ECG, electrolytes, TSH, T3, T4

Anemia CBC, creatinine, ferritin, iron, transferrin saturation, TSH, Vit

B12

Bleeding disorder (personal or family LFTs, platelet count, PT/INR, PTT

history)

Blood loss (anticipated) significant Hemoglobin, type and screen

BMI <16 Albumin, ECG, electrolytes, hemoglobin, PT/INR, TSH, T3, T4

BMI >50 ECG, HgA1c/glucose

Cardiac disease:

Arrhythmias (new or undiagnosed BNP or NT-proBNP, ECG, electrolytes, hemoglobin, TSH, T3, T4,
brady, irregular, or tachy) echocardiogram

Chest pain (new or worsening) and BNP or NT-proBNP, ECG, hemoglobin, stress test
consistent with ischemic heart
disease

Heart failure (decompensated or BNP or NT-proBNP, chest radiograph, creatinine, ECG,

NYHA class 3 or 4) electrolytes, hemoglobin, echocardiogram

Murmur (undiagnosed) BNP or NT-proBNP, ECG, echocardiogram

Chemotherapy (within last 30 days) BUN, CBC, creatinine, platelet count

CIED (pacemaker, ICD) ECG

Cocaine use ECG

Contrast dye (anticipated use) Creatinine

Diabetes Creatinine, HgA1c/glucose

Dyspnea (severe and undiagnosed) Albumin, BNP or NT-proBNP, BUN, chest radiograph,
creatinine, ECG, electrolytes, hemoglobin, TSH, T3, T4

Goiter T3, T4, TSH

Hematologic disorders (eg, leukemia, CBC, platelet count

myeloma)

Hepatic disease Albumin, BUN, creatinine, electrolytes, hemoglobin, LFTs,

platelet count, PT/INR

Hypercoagulable condition Platelet count, PTT

(undiagnosed)

Inflammatory bowel disease Electrolytes, hemoglobin

Instrumentation of the urinary tract Urinalysis

Malabsorption Albumin, BUN, CBC, electrolytes, hemoglobin, PT/INR

Malnutrition Albumin, BUN, CBC, creatinine, electrolytes, hemoglobin,

PT/INR

Medications:

Amiodarone ECG, T3, T4, TSH

Digoxin ECG, electrolytes

Diuretics Electrolytes

Heparin (unfractionated) PTT

Lithium Electrolytes, creatinine

Steroids (systemic) Electrolytes, HgA1c/glucose

Thyroid replacement TSH, T3, T4

Warfarin PT/INR

Planned initiation of warfarin for PT/INR

first time in hospital

Palpitations ECG, hemoglobin, T3, T4, TSH

Positive antibody screen on previous Type and screen (except for procedures with no blood loss
type and screen potential)

Active pulmonary disease (eg, cough, Chest radiograph

severe dyspnea, abnormal findings on
chest examination)

Pulmonary HTN ECG, BNP or NT-proBNP

Radiation therapy (to chest, breasts, Chest radiograph, ECG

lungs, thorax)

Renal disease BUN, creatinine, electrolytes, hemoglobin

Possibility of pregnancy Offer B-hCG

Syncope BNP or NT-proBNP, creatinine, ECG, electrolytes, hemoglobin,

HgA1c/glucose, TSH, T3, T4

Thyroid disease TSH, T3, T4

Tobacco use + diabetes + age >55 years Creatinine

Thrombocytopenia Platelet count

Urinary tract infection (suspected) Urinalysis; sample hold for C/S if UA suggestive of infection

Preoperative testing should be performed selectively, based on a patient's medical status, the planned
procedure, and the likelihood that test results will change management or inform risk assessment. This
table shows tests that may be considered when the clinician suspects an undiagnosed or worsening
condition, particularly when there has been no recent evaluation, when no laboratory values are
available, and for patients undergoing intermediate to high risk procedures. This table is not meant to
suggest that all of these tests should be ordered for all patients with the listed conditions. Importantly,
these are not intended as "routine" or screening tests in patients without risk factors. However, with
increasing age and comorbidities of surgical patients, organ and metabolic derangements are not
uncommon. Diagnosis and management of these conditions may impact perioperative and long term
outcomes. This table should be used in conjunction with UpToDate content on preoperative evaluation
and testing.

b-hCG: beta human chorionic gonadotropin; BNP: brain natriuretic peptide; BUN: blood urea nitrogen;
C/S: culture and sensitivity; CBC: complete blood count; CIED: cardiovascular implantable electronic
device; ECG: electrocardiogram; HbA1c: glycated hemoglobin; ICD: implantable cardioverter-defibrillator;
LFTs: liver function tests; NT-proBNP: N-terminal pro-BNP; PT/INR: prothrombin time/international
normalized ratio; PTT: partial thromboplastin time; T3: liothyronine sodium; T4: thyroxine; TSH: thyroid
stimulating hormone; UA: urine analysis.

Graphic 114157 Version 4.0

General principles for anesthesia and perioperative management for a patient

who is breastfeeding [1-3]

Preoperative planning

Ask all women with infants <2 years of age if they are breastfeeding. For those who are breastfeeding:
Where possible, day surgery is preferable to avoid disrupting normal feeding routines.
If the mother will be separated from the infant for more than a few hours perioperatively,
encourage her to express and store breast milk preoperatively to feed the infant during that time.
If the infant has not been fed from a bottle, encourage the mother to introduce bottle feeding
prior to surgery.

Selection of drugs

General Anesthetic and nonopioid analgesic drugs are generally safe for use while
principles: breastfeeding*, because they are transferred to breast milk in only very small amounts
For almost all drugs used perioperatively, there is no evidence of adverse effects on the
breastfed infant.

Optimal Opioid-sparing techniques are preferable for the breastfeeding woman. Local and
choices: regional anesthesia have benefits in this regard, and also interfere the least with the
woman's ability to care for her infant.

Use with Ketamine should be avoided if possible and should be used with careful monitoring of
caution: the infant during breastfeeding*.
Opioids and benzodiazepines should be used with caution ¶ , especially after multiple
doses and in infants <6 weeks old (corrected for gestational age). In this situation, the
infant should be observed for signs of abnormal drowsiness and ventilatory depression
especially if the woman is also showing signs of sedation.

Avoid: Codeine should not be used by breastfeeding women due to concerns of excessive
sedation in some infants, related to differences in metabolism.

Postoperative management

Women should be encouraged to breastfeed as normal following surgery.

There is no need to express and discard breast milk ("pump and dump") after anesthesia.
A woman having day surgery should have a responsible adult stay with her for the first 24 hours
postoperatively. She should be cautious with cosleeping, and be careful not to fall asleep while
feeding the infant, as she may not be as responsive as normal.
Breastfeeding support should be accessible for lactating women undergoing surgical and medical
procedures.

For most women it is safe to breastfeed as usual after anesthesia and surgery, without the need to pump
and discard breast milk. If a medication could otherwise be prescribed to the infant for a medical

condition, it is generally considered safe for the mother to take while breastfeeding. For further
information, consult the Lactmed database.

* There are limited or no data on transfer of some drugs used perioperatively to breast milk (eg,
ketamine, dexmedetomidine).

¶ Small doses of opioids and benzodiazepines are safe to use for most patients.

References:
1. Mitchell J, Jones W, Winkley E, Kinsella SM. Guideline on anaesthesia and sedation in breastfeeding women 2020. Guideline
from the Association of Anaesthetists. Anaesthesia 2020; 75:1482.
2. Reece-Stremtan S, Campos M, Kokajko L, Academy of Breastfeeding Medicine. ABM Clinical Protocol #15: Analgesia and
Anesthesia for the Breastfeeding Mother, Revised 2017. Breastfeed Med 2017; 12:500.
3. https://www.ncbi.nlm.nih.gov/books/NBK501922/ (Accessed March 17, 2021).

Graphic 131156 Version 1.0

Shared decision making

Patient is informed of all medical issues

Patient is informed of recommendations and all options for care

Patient is aware of the benefits and risks of the options of care

Patient's personal expectations and concerns are considered

Providers consider the patient's viewpoint

Providers answer all the patient's questions

Patient actively participates in all decisions

Adapted from: Flierler WJ, Nübling M, Kasper J, Heidegger T. Implementation of shared decision making in anaesthesia and its
influence on patient satisfaction. Anaesthesia 2013; 68:713.

Graphic 114031 Version 2.0

Contributor Disclosures
BobbieJean Sweitzer, MD, FACP, SAMBA-F, FASA Employment: IARS [Editor for A&A Practice].
Consultant/Advisory Boards: Becton Dickinson (Edwards Lifesciences) [Monitoring]; Medtronic [EEG
monitoring]. All of the relevant financial relationships listed have been mitigated. Kurt Pfeifer, MD, FACP,
SFHM No relevant financial relationship(s) with ineligible companies to disclose. Natalie F Holt, MD,
MPH No relevant financial relationship(s) with ineligible companies to disclose. Andrew D Auerbach, MD,
MPH Equity Ownership/Stock Options: Kuretic [Digital health app marketplace]. All of the relevant financial
relationships listed have been mitigated. Marianna Crowley, MD No relevant financial relationship(s) with
ineligible companies to disclose. Jane Givens, MD, MSCE No relevant financial relationship(s) with
ineligible companies 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

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