Preoperative Preparation

The preoperative period is a critical time for the collection and collation of pertinent patient information that is relevant and necessary for any patient scheduled for surgery. Much of this information is important for the appropriate planning of resources and disposition of patients. For example, if patient comorbidity requires postoperative intensive care unit (ICU) monitoring, this information is useful because it is acquired proactively without waiting for the day of surgery for determination. Comprehensive collection of preoperative laboratory studies, tests, and consultant notes are critical for smooth workflow on the day of surgery, thus greatly reducing delays, cancellations, and frustration for all, including patients. The following four major types of preoperative models are in use today. (A more complete description of these models can be found in Preoperative Systems by Young and Gibby.¹)

1. Surgeon’s office evaluation and triage. Typically, the surgeon’s office has the sole responsibility for ordering specific preoperative tests, lab studies, and/or coordinating consultant evaluations. Not uncommonly, the surgeon may carry out “shot-gun” testing of patients to preclude surgical delays due to missing lab studies or tests—a common source of unnecessary lab testing.² In addition, even when the surgeon hand-carries information to the operating room, delays are common because this information is not available for review by anesthesia staff before the day of surgery. Faxing this information into the operating room or similar chart area is fraught with missing documentation and is a common source of frustration.

2. Preoperative phone triage. In this setting, hospital nurses most commonly telephone patients directly to capture health history. Under ideal situations, these nurses have had special training and work with the anesthesia team to identify high-risk or special-needs patients who can be allocated into alternative care plans or coordinated care that is more effectively accomplished before the day of surgery. Problems with this approach are dependency on patient information and the high costs associated with staffing nurses for this role. Surgical planning is typically independent and is managed predominantly through the operating room scheduling system that governs equipment and personnel.

3. Nurse-managed preoperative clinics. In a specific clinic typically within the hospital environment, patients may be required to visit to provide histories and some components of the physical exam. Frequently, lab tests and other tests are performed at these clinics and have been shown to reduce unnecessary testing ³ and improve patient satisfaction.⁴ Again, the high costs of staffing and managing preclude thorough dissemination of these clinics. Though more comprehensive than the telephone triage system, these clinics may be inconvenient for patients who do not need or want another visit to the hospital.

4. Computerized physician-run clinics. In a small minority of clinics, patients are required to complete a full history and questionnaire online, which feeds a specific rules-based engine that helps guide the triage process and may guide preoperative testing and consultations. An example of this type of clinic is the Cleveland Clinic, which has created a preoperative clinic manned by physicians and physician extenders. Each patient must complete a thorough questionnaire online, and if the patient is unable to interact with the system, the surgeon’s office is responsible for guiding the patient through the process. This type of clinic appears to be a distinct possibility in the future because it helps to define preoperative testing based on evidence-based guidelines, thus reducing unnecessary testing and more effectively triaging patients to appropriate caregivers.

Effective preoperative preparation essentially helps to establish appropriate risk stratification of patients. Waiting until the day of surgery to define surgical risk stratification is too late. Creating specific care plans requires careful assignment to appropriate risk stratagems; presently even most pay-for-performance measures are pushing all providers to identify at-risk patients. It is impossible to adequately allocate patients into appropriate risk classification without an assessment of patient comorbidities as well as recognized surgical risk categories. The American Society of Anesthesia (ASA) has established a risk stratification system based on medical conditions that have intermediate benefit in proactively identifying a patient’s surgical risk. Referred to as the ASA classification system, patients are classified from ASA I to ASA VI (Table 11-1). Unfortunately, this classification is very subjective and has not been shown to be extremely effective in assigning risk.⁵ An alternative risk model was proposed by Pasternak⁶ and defines five categories of risk based on predicted blood loss. Neither of these two categories has ever been demonstrated to correlate with outcomes, but for purposes of risk stratification, some methodology is required. Most colorectal surgery should qualify as being associated with intermediate risk; however, certain patients may in fact have high surgical risk, particularly those with major vascular involvement. Patients’ medical comorbidities are not as simply defined. The presence of major cardiac, pulmonary, renal, or other organ dysfunction has serious implications regarding the postoperative outcomes of patients. The next section identifies and discusses specific concerns regarding particular systems:

Table 11-1 American Society of Anesthesia Classification System

ASA	Definition
I	Primarily healthy patients with no existing comorbid conditions; typically taking no medications and very active physically.
II	Patients with well-controlled medical problems. This may include patients on no medications but who are obese or smoke cigarettes. No acute exacerbations of their medical conditions prior to surgery.
III	Patients with established medical conditions that are not well controlled. May also include patients with multiple medical conditions such as patients with a previous myocardial infarction, diabetes, obesity, and renal insufficiency.
IV	Patients with extensive medical problems who have a definitive possibility of not surviving this operation or hospitalization.
V	Patients who are moribund and for whom heroic surgery may be the only option.
VI	Brain-dead organ harvest patients. No chance of survival.

One of the authors (JS) has created a preoperative roadmap that has been deployed at the Johns Hopkins Medical Institutions and that provides some guidance for surgeons regarding how to order preoperative testing as well as how to determine which patients should be seen in a preoperative evaluation clinic (PEC). This roadmap contains sections that define generic testing guidelines (Box 11-1). Additional recommendations based on types of comorbidities are provided in Table 11-2. This roadmap also has recommendations regarding which medications to hold versus medications to instruct patients to take on the morning of surgery (Table 11-3). More and more often, we are advocating that patients take their morning medications before surgery, specifically medications such as cardiac medication, statins, and proton pump inhibitors. Other medications such as oral hypoglycemic agents are currently being recommended to be held on the morning of surgery. In fact, one of the new Surgical Care Improvement Project (SCIP) measures targets the administration of beta blockers within 24 hours of surgery to patients currently taking these medications.⁷

Do Not

• No chest x-ray unless a history of pulmonary dysfunction with no previous chest x-ray for 1 year.

• No PT/PTT (prothrombin time/partial thromboplastin time) except in patient with a history of bleeding or easy bruising. If ordering these tests, order only PT, not PTT (reserved for patients on heparin).

Table 11-2 Medical Conditions with Specific Testing Recommendations

Condition	Testing Recommendation
Diabetes	Fasting basic metabolic profile (BMP); electrocardiogram (ECG) for all patients older than 20 years
Hypertension or cardiac disease	BMP; ECG; consider echocardiography (ECHO), stress test, and/or cardiac evaluation if symptoms significant
Chronic obstructive pulmonary disease	Pulmonary function tests (PFTs) if symptoms are significant
Anemia and/or bleeding history	Heme 8; Consider prothrombin time (PT). Auto-donors need to have hemoglobin/hematocrit (Hb/HCT) after donation (morning of surgery should be adequate)
Liver dysfunction or malnutrition	Comprehensive metabolic profile (CMP), Heme 8, PT
High-risk surgical procedures (major blood loss expected)	Heme 8; CMP, PT; consider ECHO, stress test, and/or cardiac evaluation if medical condition warrants
Poor exercise tolerance	Heme 8; CMP; ECG; primary medical doctor evaluation; consider ECHO, stress test, and/or cardiac evaluation
Morbid obesity	BMP; CMP; ECG; consider ECHO (must rule out pulmonary hypertension), stress test, and/or cardiac evaluation
End-stage renal disease (dialysis patient)	Postdialysis lab tests to include Heme 8 and BMP at a minimum; sodium/potassium (Na/K) on morning of surgery
Pacemaker	Must be interrogated within 6 months, and have report on chart. Pacer-dependent patients and those with implantable cardioverter defibrillator (ICD) devices must be interrogated within 3 months. ICD patients need device turned off morning of surgery

Table 11-3 Medications to Hold on Day of Surgery

Class	Medication	Recommendation
Oral hypoglycemic agents	Metformin (Glucophage), pioglitazone (Actos), glyburide, tolazamide (Tolinase), rosiglitazone (Avandia), glimepiride (Amaryl), all others	Hold at least 8 hours before surgery. Recommend holding morning dose on day of surgery
Diuretics	Furosemide (Lasix), hydrochlorothiazide (HCTZ)	Hold on morning of surgery, unless prescribed for congestive heart failure (CHF) (CHF patients should take their morning dose of diuretics)
ACE inhibitors/ARBs	Lisinopril, amlodipine/benezepril (Lotrel) captopril, hydrochlorothiazide/benazepril, (Lotensin), fosinopril (Monopril), lisinopril/hydrochlorothiazide (Prinzide), candesartan cilexetil (Atacand), olmesartan medoxomil (Benicar), valsartan (Diovan), irbesartan/hydrochlorothiazide (Avalide)	Hold on morning of surgery, unless prescribed for CHF (CHF patients should take their morning dose of medications)
Insulin	NPH, Regular	Hold insulin on morning of surgery. Bring insulin with patient to hospital
Alternative therapies	Herbal supplements	Stop at least 24 hours before surgery