Preoperative Examination

1. See Also
   1. Preoperative Cardiovascular Evaluation
   2. Preoperative Evaluation in Kidney Disease
   3. Perioperative Beta Blocker
   4. Antiplatelet Therapy for Vascular Disease
   5. Perioperative Cardiovascular Risk
   6. Perioperative Diabetes Management
   7. Deep Vein Thrombosis Prevention
   8. Perioperative Anticoagulation
   9. Endocarditis Prophylaxis
   10. Postoperative Nausea and Vomiting Prevention
2. Protocol: NPO guidelines
   1. No Solid foods within 6 hours of surgery
      1. Includes Orange juice, Soda, and Milk
   2. No clear liquids with 2 hours of surgery
      1. Includes water and apple juice
   3. Medications to still take on morning of surgery
      1. All Cardiovascular medications (except Diuretics)
      2. Anti-reflux medications (e.g. Omeprazole, Ranitidine)
      3. Seizure and anti-parkinson medications
      4. Bronchodilators (bring Asthma inhalers to hospital on day of surgery)
      5. CPAP machine (and bring to hospital on day of surgery)
      6. Oral Contraceptives
      7. Corticosteroids or immunosuppressants
      8. Levothyroxine (Synthroid)
      9. Insulin is typically taken at half dose (see Perioperative Diabetes Management)
      10. Pain medications
          1. Acetaminophen or opiates
          2. Not Aspirin or NSAIDS
   4. Medications to not take on morning of surgery
      1. See Perioperative Medication Guidelines below
      2. Diabetes medications
         1. See Perioperative Diabetes Management
         2. Oral diabetes medications are typically held on the day of surgery
      3. Diuretics or weight loss medications
      4. Potassium supplements or vitamins
3. Protocol: Medications recommended if Cardiac Risk Factors
   1. See Preoperative Cardiovascular Evaluation
   2. Beta Blockers
      1. See Perioperative Beta Blocker
      2. New AHA guidelines (2009) suggest to continue Beta Blockers if already started
      3. However, do not start a preoperative Beta Blocker without careful consideration
         1. If started, initiate early (at least 2-4 weeks before surgery)
         2. Titrate to Heart Rate of 60-80 and avoid Hypotension (monitor preoperatively after starting)
   3. Statin medications
      1. Consider delaying surgery 1 month to start Statin before the procedure if significant cardiovascular risks
         1. Statins reduce risk of perioperative adverse cardiovascular event with Number Needed to Treat of 13
         2. Schouten (2009) N Engl J Med 361(10) 980-89
      2. Do not stop Statin drugs in the perioperative period
         1. Significant increased risk of cardiovascular events on abruptly stopping Statins
            1. Le Manach (2007) Anesth Analg 104(6): 1326-33
            2. Schouten (2007) Am J Cardiol 100(2): 316-20
         2. Restart Statin within 1 day postoperatively
         3. Consider perioperative use of extended release Statin such as Lovastatin or Fluvastatin
   4. Antiplatelet agents
      1. See Antiplatelet Therapy for Vascular Disease
      2. Do not stop antiplatelet agents without carefully reviewing indications
      3. See Medications to Avoid Prior to Surgery
4. Protocol: Medications to avoid in perioperative period
   1. Medications associated with bleeding risk
      1. See Perioperative Anticoagulation
      2. Aspirin, Clopidogrel, Dipyridamole, (Ticlopidine)
         1. Do not stop antiplatelet agents without carefully reviewing indications
            1. See Antiplatelet Therapy for Vascular Disease
         2. Stop 7 days before surgery if no contraindication to stopping
         3. May continue for dental surgeries and Cataracts
      3. Warfarin: Stop 5 days before surgery
         1. See Warfarin Protocol for the Perioperative Period
      4. NSAIDs (e.g. Ibuprofen): Stop 5 days before surgery
      5. COX2 Inhibitors (e.g. Celebrex, Vioxx)
         1. Does not need to be discontinued before surgery
   2. Ophthamologic surgery: Cataract
      1. Notify surgeon of Flomax use in the perioperative period (due to risk of floppy iris syndrome)
         1. Ophthalmologists can take preventive measures at surgery if they know of Flomax use
         2. As a long-acting medication, stopping the medication immediately before the procedure will not alter the risk
   3. Parkinsonism Agents
      1. MAO inhibitors should be tapered off 2-3 weeks before the procedure (due to anesthesia drug interactions)
         1. Includes Selegiline and Rasagiline
      2. Avoid stopping Sinemet in perioperative procedure (risk of Parkinsonian hyperpyrexia syndrome)
      3. Stay moving in the post-operative period (within 2-3 days of procedure - incorporate PT/OT)
   4. Miscellaneous
      1. Tamoxifen (associated with thromboembolism)
   5. Herbal preparations to avoid in perioperative period
      1. Echinacea
      2. Ephedra (should be avoided in general)
      3. Garlic (discontinue at least 7 days before surgery)
      4. Gingko (discontinue at least 36 hours before surgery)
      5. Ginseng (discontinue at least 7 days before surgery)
      6. Kava (discontinue at least 24 hours before surgery)
      7. St. John's Wort (stop at least 5 days before surgery)
      8. Valerian (slowly taper off before surgery)
      9. Ang-Lee (2001) JAMA 286:208-16
5. Labs: Preoperative
   1. History and physical directs lab screening
   2. Otherwise healthy patient for a non-high risk procedure
      1. No routine laboratory testing indicated
      2. Consider a Pregnancy Test in all fertile women
   3. Hemoglobin indications
      1. Anemia History
      2. Blood loss anticipated with procedure
   4. Serum Potassium
      1. Diuretic (e.g. Furosemide) use
      2. Digoxin use
   5. ProTime and INR
      1. Coagulopathy history
      2. Anticoagulant use or anticipated use post-surgery
   6. Chest XRay
      1. Change in cardiopulmonary status
   7. Electrocardiogram within last year
      1. Cardiac Risk Factors
      2. Age over 55 years