Preoperative Evaluation and Coexisting Disease
Risk is a probability, not a diagnosis
Preoperative evaluation estimates perioperative risk and identifies modifiable disease. Cover functional capacity (METs), cardiovascular risk (RCRI, ACS-NSQIP), pulmonary risk (COPD, smoking, OSA, spirometry when indicated), renal and hepatic disease, diabetes, anticoagulation, anemia, frailty, and substance use. Understand fasting guidelines, premedication, consent, and documentation. Routine testing is low-value in asymptomatic patients; test when results change management.
Traps: do not order stress tests merely to clear a patient-most stable patients proceed without revascularization. Beta blockers should not be started on the day of surgery solely for risk reduction. Dual antiplatelet therapy after coronary stenting requires cardiology input. OSA screening does not automatically mandate postoperative ICU. An abnormal lab may be chronic and irrelevant; compare with baseline.
Worked example: a 72-year-old with prior MI, insulin-dependent diabetes, and creatinine 1.8 undergoes elective hip surgery. RCRI components include ischemic heart disease, heart failure, cerebrovascular disease, insulin-treated diabetes, creatinine above 2.0, and high-risk surgery. This patient has two or three depending on creatinine; plan optimization, avoid dehydration, and consider postoperative monitoring rather than reflexive angiography.
Rule of thumb: optimize the disease, not the number-unless the number will change anesthetic or surgical management.