The purpose of a preoperative evaluation is not to “clear” patients for elective surgery, but rather to evaluate and, if necessary, implement measures to prepare higher risk patients for surgery. Pre-operative outpatient medical evaluation can decrease the length of hospital stay as well as minimize postponed or cancelled surgeries.1 To effectively provide this consultative service, the physician should understand the risk associated with the particular type of surgery planned and relate this risk to the patient's underlying acute and chronic medical problems. The complete consultation should include recommendations for evaluation and treatment, including prophylactic therapies to minimize the perioperative risk.

 The overall risk for surgical complications depends on individual factors and the type of surgical procedure. For example, advanced age places a patient at increased risk for surgical morbidity and mortality.3,4 The reason for an age-related increase in surgical complications appears to correlate with an increased likelihood of underlying disease states in older persons, because studies have found that healthy elderly patients have surgical complication rates comparable to those of healthy younger patients.5,6 Diseases associated with an increased risk for surgical complications include respiratory and cardiac disease, malnutrition and diabetes mellitus.7 With respect to the type of surgery, urgent and emergency procedures constitute higher risk situations than elective, nonurgent surgery and present a limited opportunity for preoperative evaluation and treatment.

Preoperative History  and Physical Examination

The patient should ideally be evaluated several weeks before the operation. The history should include information about the condition for which the surgery is planned, any past surgical procedures and the patient's experience with anesthesia. In children, the history should also include birth history, focusing on risk factors such as prematurity at birth, perinatal complications and congenital chromosomal or anatomic malformations, and history of recent infections, particularly upper respiratory infections or pneumonia.

The physician should inquire about any chronic medical conditions, particularly of the heart and lungs. Medications (including over-the-counter medications) should be noted. Drug dosages may need to be adjusted in the perioperative period. Aspirin and non-steroidal anti-inflammatory drugs should be discontinued one week before surgery to avoid excessive bleeding.

Immunization status can be documented, and vaccines can be updated if necessary. The patient should be asked about smoking history and alcohol and drug use. Ideally, the patient should quit smoking eight or more weeks before surgery to minimize the surgical risk associated with smoking.8

A functional assessment should be performed, and the physician should review the patient's social support and need for assistance after hospital discharge. For example, a patient who is scheduled for hip replacement surgery and has limited assistance available at home may require home services or temporary placement in a rehabilitation facility. Plans for such assistance can be made before hospitalization.

Patients with cardiopulmonary disease may warrant a second examination just before hospitalization. In a child with an upper respiratory tract infection, a second visit to assess the current status of the infection can allow consultation with the surgeon regarding the need to postpone the procedure because of persistent fever, wheezing or significant nasal discharge.   Journal of Perioperative Medicine