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Preoperative Medical Optimization

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Preoperative Medical Optimization

Comprehensive exam-focused review of Preoperative Medical Optimization including clinical presentation, investigation, management, and key exam points

complete
Updated: 2025-12-24
High Yield Overview

PREOPERATIVE MEDICAL OPTIMIZATION

Risk Stratification | Cardiovascular Assessment | Medication Management | Functional Capacity

4 METsfunctional capacity threshold
30%reduction in complications with optimization
1-4%perioperative MI risk in elective orthopaedics
48-72hsmoking cessation minimum benefit

ASA Physical Status Classification

ASA 1
PatternHealthy patient
TreatmentRoutine care
ASA 2
PatternMild systemic disease
TreatmentStandard care with monitoring
ASA 3
PatternSevere systemic disease
TreatmentOptimize before surgery
ASA 4
PatternLife-threatening disease
TreatmentICU planning, HDU postop

Critical Must-Knows

  • Functional capacity under 4 METs predicts increased perioperative cardiac complications
  • Beta-blockers should NOT be started perioperatively - increased stroke risk (POISE trial)
  • Metformin cessation required on day of surgery to reduce lactic acidosis risk
  • Aspirin continuation recommended for patients with coronary stents in past 12 months
  • Delay elective surgery 4-6 weeks after acute MI or coronary intervention

Examiner's Pearls

  • "
    RCRI score (Revised Cardiac Risk Index) stratifies cardiac risk - 6 predictors
  • "
    Stop smoking minimum 4 weeks before surgery for wound healing benefit
  • "
    HbA1c greater than 8.5% associated with increased infection and complications
  • "
    Patients on oral anticoagulants need bridging plan individualized to thrombotic risk

Critical Preoperative Optimization Exam Points

Cardiac Risk Assessment

RCRI score is gold standard. Six predictors: high-risk surgery, ischemic heart disease, heart failure, stroke/TIA, diabetes on insulin, creatinine greater than 177. Score greater than 2 requires cardiology input.

Functional Capacity

Under 4 METs = high risk. Cannot climb 2 flights of stairs or walk 4 blocks = poor functional capacity. Requires further cardiac testing before major surgery.

Medication Management

STOP: warfarin 5 days, clopidogrel 5-7 days, DOACs 24-48h. CONTINUE: aspirin (unless neurosurgery), beta-blockers, statins, ACE inhibitors. START: nothing new perioperatively.

Diabetic Control

HbA1c greater than 8.5% = delay elective surgery. Day of surgery: hold metformin, reduce long-acting insulin by 20-25%, IV dextrose if NPO greater than 6 hours.

Principles of Risk Stratification

ASA Physical Status Classification

ASA ClassDefinitionExamplesPerioperative Management
ASA 1Healthy patientNo organic, physiologic, biochemical abnormalityRoutine perioperative care
ASA 2Mild systemic diseaseWell-controlled HTN, BMI 30-40, social smokerStandard care with monitoring
ASA 3Severe systemic diseasePoorly controlled DM, COPD, BMI greater than 40, active smokerPreoperative optimization, HDU consideration
ASA 4Life-threatening diseaseRecent MI under 3 months, sepsis, ESRFICU planning, intensivist involvement

Revised Cardiac Risk Index (RCRI)

RCRI Score Interpretation and Management

0.4-1% event rateScore 0-1 (Low Risk)

Management: Proceed with surgery. No further cardiac testing needed. Routine perioperative care.

2.4% event rateScore 2 (Intermediate Risk)

Management: Consider cardiology consultation. Assess functional capacity - if greater than 4 METs, proceed. If under 4 METs or unknown, consider stress testing.

greater than 5.4% event rateScore 3+ (High Risk)

Management: Cardiology consultation mandatory. Functional capacity assessment. Stress testing or coronary imaging. May need coronary revascularization before surgery.

Functional Capacity Assessment

4 METs is the critical threshold. Activities requiring 4 METs: climb 2 flights of stairs, walk 4 blocks on level ground, do heavy housework. Patients unable to achieve 4 METs have significantly increased perioperative cardiac complications and require further evaluation before major surgery.

Cardiac Testing Indications

When to Order Stress Testing

  • RCRI score greater than 2 AND functional capacity under 4 METs
  • Recent MI (4-6 weeks ago) before elective surgery
  • Unstable angina or decompensated heart failure
  • High-risk surgery (vascular, prolonged)

Avoid Unnecessary Testing

  • Good functional capacity (greater than 4 METs) regardless of RCRI
  • Low-risk surgery (arthroscopy, minor procedures)
  • Recent stress test (under 1 year) with no change in status
  • Asymptomatic patient with ASA 1-2

Clinical Relevance - Respiratory Optimization

ARISCAT Score for Pulmonary Risk

ARISCAT Risk Factors

FactorPointsClinical Significance
Age 50-80 years3 pointsDecreased respiratory reserve
Age greater than 80 years16 pointsHigh risk group
SpO2 under 96%8 pointsBaseline hypoxemia
Respiratory infection in last month17 pointsActive inflammation
Anemia (Hb under 100 g/L)11 pointsImpaired oxygen delivery
Upper abdominal or thoracic surgery15 pointsDirect pulmonary impact

Smoking Cessation

Smoking Cessation Benefits

Immediate48-72 hours

Reduced carbon monoxide levels. Improved oxygen-carrying capacity. Decreased sputum production begins.

Short-term4 weeks

Improved mucociliary function. Reduced postoperative pulmonary complications by 20%. Sputum volume normalized.

Optimal8 weeks

Significant reduction in wound complications. Improved immune function. Cardiovascular benefits established.

Timing Controversy

Cessation under 4 weeks may INCREASE pulmonary complications due to increased sputum production. Minimum 4 weeks required for benefit. If patient cannot stop 4+ weeks before, continue smoking up to surgery rather than stopping 1-2 weeks before.

Preoperative Smoking Optimization

Counseling: Motivational interviewing, nicotine replacement (patches/gum), varenicline (Champix), Quitline 13 7848.

Intraoperative: Increased airway reactivity (use bronchodilators), target SpO2 greater than 95%, aggressive pulmonary toilet, early mobilization.

Medication Management

Anticoagulation and Antiplatelet Agents

Warfarin Management Protocol

Perioperative Warfarin Protocol

Pre-op5 days before

Stop warfarin. Check INR. Assess thrombotic risk: mechanical heart valve, atrial fibrillation with CHADS2 greater than 4, VTE under 3 months = HIGH RISK (bridge with LMWH).

Pre-op checkDay before surgery

Confirm INR under 1.5. If still elevated, consider vitamin K 1-2 mg PO. Last LMWH dose 24h before surgery if bridging.

PerioperativeDay of surgery

INR under 1.5 for neuraxial anesthesia. Proceed with surgery. Document hemostasis achieved.

12-24h afterPostoperative

Resume warfarin evening of surgery or next morning if good hemostasis. Restart LMWH bridging 24h post-op if high thrombotic risk.

Antiplatelet Agent Management

AgentMechanismStop Before SurgerySpecial Considerations
Aspirin 100mgCOX-1 irreversible inhibitor7 days (context-dependent)CONTINUE if coronary stent under 12 months or recent MI
ClopidogrelP2Y12 inhibitor5-7 daysDual antiplatelet if stent - cardiology consult required
TicagrelorReversible P2Y12 inhibitor5 daysFaster offset than clopidogrel - useful for urgent surgery
PrasugrelP2Y12 inhibitor7 daysMost potent - highest bleeding risk

Coronary Stent Considerations

Bare metal stent: minimum 30 days dual antiplatelet therapy. Drug-eluting stent: minimum 6-12 months dual antiplatelet therapy. Premature cessation risks stent thrombosis (20-45% mortality). Consult cardiology before stopping - may continue aspirin + clopidogrel through surgery for some procedures.

Summary: Individualize antiplatelet management based on stent type, timing, and thrombotic risk.

Direct Oral Anticoagulant (DOAC) Management

DOACHalf-lifeRenal ClearanceStop Before Surgery (CrCl greater than 50)
Apixaban (Eliquis)12 hours27%24-48h before
Rivaroxaban (Xarelto)5-9 hours33%24-48h before
Dabigatran (Pradaxa)12-17 hours80%48-72h if CrCl under 50
Edoxaban (Lixiana)10-14 hours50%24-48h before

DOAC Reversal Agents

Dabigatran: idarucizumab (Praxbind) - monoclonal antibody, immediate reversal. Xa inhibitors (apixaban, rivaroxaban, edoxaban): andexanet alfa (limited availability) or 4-factor PCC (Prothrombinex). No bridging needed for DOACs - restart 24-48h post-op when hemostasis secure.

Summary: DOAC management simpler than warfarin - no bridging required, predictable offset based on half-life.

Diabetic Medications

Day of Surgery - Type 1 Diabetes

  • Basal insulin: reduce long-acting (glargine, detemir) by 20-25%
  • Bolus insulin: hold short-acting
  • IV dextrose: 5% dextrose with insulin sliding scale if NPO greater than 6h
  • BGL monitoring: hourly intraoperatively, 2-hourly postop
  • Target BGL: 6-10 mmol/L perioperatively

Day of Surgery - Type 2 Diabetes

  • Metformin: HOLD on day of surgery (lactic acidosis risk)
  • Sulfonylureas: HOLD on day of surgery (hypoglycemia risk)
  • SGLT2 inhibitors: HOLD 3 days before (DKA risk)
  • GLP-1 agonists: HOLD on day of surgery
  • DPP-4 inhibitors: can continue
  • Insulin: reduce basal by 20-25%, hold bolus

HbA1c Threshold for Elective Surgery

HbA1c greater than 8.5% (greater than 69 mmol/mol) associated with significantly increased perioperative complications: infection (2-3x risk), wound dehiscence, prolonged LOS, ICU admission. Consider delaying elective surgery to optimize control. Minimum 6-8 weeks needed to improve HbA1c. Discuss risk vs benefit with patient and anesthetist.

Cardiovascular Medications

Perioperative Management of Cardiac Medications

MedicationPerioperative ActionRationale
Beta-blockers (established use)CONTINUEWithdrawal causes rebound tachycardia and ischemia. Continue at same dose.
Beta-blockers (new start)DO NOT STARTPOISE trial: increased stroke and mortality. Only continue if already established.
ACE inhibitors/ARBsCONTINUE (controversial)May cause intraoperative hypotension. Some hold on day of surgery. No consensus.
StatinsCONTINUEAnti-inflammatory effect. Reduced perioperative MI. Give night before surgery.
DiureticsHOLD on day of surgeryRisk of hypovolemia and electrolyte disturbance.

Laboratory and Investigation Optimization

Preoperative Testing Guidelines

Age and ASA-Based Testing

TestASA 1-2 Under 40ASA 1-2 Over 40ASA 3-4 Any Age
FBCNot routineIf significant blood loss expectedAlways
UECNot routineIf on ACE-I, diuretics, diabetesAlways
GlucoseNot routineIf diabetic or obeseAlways
CoagulationOnly if bleeding historyIf on anticoagulationIf liver disease or anticoagulated
ECGNot routineOver 45 or cardiac historyAlways
CXRNot routineIf cardiopulmonary symptomsIf moderate-severe lung/cardiac disease

Avoid Unnecessary Testing

Routine preoperative testing in healthy patients (ASA 1-2) undergoing low-risk procedures does NOT improve outcomes and delays surgery. Test based on patient comorbidities and procedure risk, not age alone. Australian guidelines (ANZCA): no routine testing for ASA 1-2 patients under 40 years.

Summary: Targeted testing based on clinical assessment more valuable than blanket screening.

Preoperative Anemia Optimization

Anemia Workup and Management

4-6 weeks pre-opIdentify Anemia

Screen high-risk patients: age greater than 65, known CKD, inflammatory arthritis, previous transfusion history. Check FBC, iron studies (ferritin, transferrin saturation), B12, folate.

Diagnostic phaseDetermine Cause

Iron deficiency: ferritin under 30 or TSAT under 20%. Chronic disease: high ferritin, low TSAT. B12/folate deficiency: macrocytic anemia. CKD: low EPO production.

4 weeks minimumTreat Underlying Cause

Iron deficiency: oral iron 200mg elemental iron daily OR IV iron (ferinject 1000mg) if oral not tolerated or time-critical. B12 deficiency: IM hydroxocobalamin. EPO: if CKD and Hb under 100.

1 week beforeRecheck Pre-op

Confirm response: expect Hb rise 10-20 g/L with 4 weeks treatment. Document improvement. Plan transfusion if still under threshold and unable to delay.

Summary: Treating preoperative anemia reduces transfusion requirements and improves outcomes.

Evidence Base and Key Trials

POISE Trial - Beta-Blocker Initiation

1
POISE Study Group • Lancet (2008)
Key Findings:
  • 8351 patients with atherosclerotic disease undergoing noncardiac surgery
  • Randomized to metoprolol vs placebo started on day of surgery
  • Reduced perioperative MI (OR 0.73) BUT increased stroke (OR 2.17) and mortality (OR 1.33)
  • Bradycardia and hypotension more common with metoprolol
Clinical Implication: Do NOT start beta-blockers perioperatively. Only continue if patient already established on therapy.
Limitation: High-dose metoprolol used. Does not apply to patients on chronic beta-blocker therapy.

Smoking Cessation and Wound Complications

2
Sorensen et al • Annals of Surgery (2003)
Key Findings:
  • Prospective study of 120 patients randomized to smoking cessation vs control
  • 6-8 weeks cessation intervention before hip or knee arthroplasty
  • Wound complications reduced from 31% to 5% with cessation
  • Overall complications reduced from 52% to 18%
Clinical Implication: Minimum 4 weeks smoking cessation significantly reduces wound and overall complications.
Limitation: Small study. Benefit requires minimum 4 weeks - shorter duration may increase sputum production.

Revised Cardiac Risk Index Validation

2
Lee et al • Circulation (1999)
Key Findings:
  • 4315 patients undergoing noncardiac surgery - derivation cohort
  • 6 independent predictors identified: high-risk surgery, ischemic heart disease, CHF, CVA, DM on insulin, Cr greater than 2
  • Risk of major cardiac events: 0 factors 0.4%, 1 factor 0.9%, 2 factors 6.6%, 3+ factors 11%
  • Validated in separate cohort of 1422 patients
Clinical Implication: RCRI is gold standard for perioperative cardiac risk stratification.
Limitation: Developed for major noncardiac surgery. May overestimate risk for minor procedures.

Preoperative HbA1c and Complications

2
Marchant et al • Journal of Bone and Joint Surgery Am (2009)
Key Findings:
  • 504 patients undergoing elective total joint arthroplasty
  • HbA1c greater than 7% associated with increased infection risk (OR 1.7)
  • Each 1% increase in HbA1c increased infection risk by 30%
  • HbA1c greater than 8.5% had 3-fold increased risk of any complication
Clinical Implication: Delay elective orthopaedic surgery if HbA1c greater than 8.5% to optimize diabetic control.
Limitation: Observational study. Optimal HbA1c threshold remains debated (some suggest under 8%, others under 7%).

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Scenario 1: High-Risk Cardiac Patient

EXAMINER

"68-year-old male for elective THA. Previous MI 18 months ago (DES), diabetes on insulin, Cr 160. On aspirin, ticagrelor, metoprolol. Climbs 1 flight only. How to optimize?"

EXCEPTIONAL ANSWER
High-risk patient. RCRI score 3 (IHD, DM on insulin, renal impairment) = greater than 5% cardiac event risk. Functional capacity under 4 METs is concerning. DES at 18 months - cardiology input for DAPT modification. Continue aspirin and metoprolol, stop ticagrelor 5 days pre-op after cardiology approval, reduce insulin 25% on surgery day, hold ramipril. Plan HDU postop.
KEY POINTS TO SCORE
RCRI score 3 = high risk, needs optimization
Under 4 METs functional capacity mandates evaluation
Never stop established beta-blockers
COMMON TRAPS
✗Starting new beta-blocker (POISE - increases stroke)
✗Stopping all antiplatelets without cardiology input
LIKELY FOLLOW-UPS
"Threshold for stress testing? (RCRI greater than 2 AND under 4 METs)"
"What if cardiology wants to continue DAPT?"
VIVA SCENARIOChallenging

Scenario 2: Diabetic Control

EXAMINER

"62-year-old female, HbA1c 9.8%, listed for revision TKA in 2 weeks. Previous wound infections. Patient keen to proceed. Your plan?"

EXCEPTIONAL ANSWER
Delay surgery. HbA1c 9.8% (84 mmol/mol) is well above 8.5% threshold - associated with 2-3x infection risk. Previous infections make this critical. Requires 6-8 weeks minimum for optimization. Refer to GP/endocrinology, target HbA1c under 8%, recheck in 8 weeks. Patient pressure does not override medical safety. If proceeds now: high risk of wound dehiscence, deep infection, treatment failure.
KEY POINTS TO SCORE
HbA1c greater than 8.5% mandates delay of elective surgery
6-8 weeks minimum for HbA1c improvement
Previous infections amplify risk
COMMON TRAPS
✗Proceeding due to patient/administrative pressure
✗Thinking tight periop glucose compensates for chronic hyperglycemia
LIKELY FOLLOW-UPS
"What HbA1c threshold for elective surgery? (under 8-8.5%)"
"Day of surgery medication management?"

MCQ Practice Points

RCRI Components

Q: Which of the following is NOT a component of the Revised Cardiac Risk Index? A: Hypertension. The six RCRI predictors are: high-risk surgery, ischemic heart disease, CHF, cerebrovascular disease, diabetes on insulin, and creatinine greater than 177.

Functional Capacity Threshold

Q: What functional capacity threshold predicts increased perioperative cardiac complications? A: Under 4 METs. Patients unable to climb 2 flights of stairs or walk 4 blocks have significantly increased cardiac risk.

POISE Trial Finding

Q: What did the POISE trial demonstrate about starting beta-blockers perioperatively? A: Increased stroke (OR 2.17) and mortality despite reducing MI. Only continue beta-blockers if patient already established on therapy.

Australian Context and Guidelines

ANZCA Guidelines: PS07 (pre-anesthesia consultation), PS18 (fasting), PS51 (smoking cessation), PS53 (blood management). No routine testing for ASA 1-2 patients.

Australian Resources: eTG (antibiotic prophylaxis), PBS (medication costs), Quitline 13 7848 (smoking cessation).

Medicolegal: Document ASA/RCRI scores, informed consent with patient-specific risks, medication plan. Common litigation: failure to identify high-risk patients, anticoagulation errors, proceeding despite modifiable risk factors.

PREOPERATIVE MEDICAL OPTIMIZATION

High-Yield Exam Summary

RCRI Score (6 Predictors)

  • •HI DISC: High-risk surgery, Ischemic heart disease, Diabetes on insulin, Impaired renal (Cr greater than 177), Stroke/TIA, CHF
  • •Score 0-1 = low risk (0.4-1%), proceed with surgery
  • •Score 2 = intermediate (2.4%), assess functional capacity
  • •Score 3+ = high risk (greater than 5%), cardiology consult

Functional Capacity

  • •4 METs = critical threshold (climb 2 flights, walk 4 blocks)
  • •Under 4 METs + RCRI greater than 1 = further cardiac testing
  • •Good functional capacity (greater than 4 METs) = proceed regardless of RCRI

Medication Management

  • •STOP: warfarin 5d, clopidogrel 5-7d, metformin day of, SGLT2i 3d before
  • •CONTINUE: aspirin (if stent under 12mo), beta-blockers, statins
  • •NEVER START: new beta-blockers perioperatively (POISE - increased stroke)
  • •DOACs: stop 24-48h depending on renal function, no bridging needed

Diabetic Optimization

  • •HbA1c greater than 8.5% = delay elective surgery 6-8 weeks to optimize
  • •Day of surgery: hold metformin, reduce basal insulin 20-25%, hold bolus insulin
  • •IV dextrose if NPO greater than 6h, target BGL 6-10 mmol/L
  • •Poor control = 2-3x infection risk

Smoking and Anemia

  • •Minimum 4 weeks cessation for benefit - under 4 weeks may worsen outcomes
  • •Optimal cessation 8 weeks - reduces wound complications from 31% to 5%
  • •Anemia: treat if Hb under 130 (M) or 120 (F), IV iron if time-critical
  • •Expect Hb rise 10-20 g/L with 4 weeks treatment
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Reading Time54 min
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