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EHPLE Anesthesia study materials
EHPLE Anesthesia study resources

EHPLE Anesthesia: Preoperative Assessment and Patient Optimization

EHPLE Anesthesia · Work through your exam, one topic at a time.

All guide sections

Preoperative Assessment and Patient Optimization

What this domain tests

Preoperative items test whether you can stratify risk, decide which tests change management, and optimize comorbid disease without delaying necessary surgery.

Core rules

  • RCRI predictors: high-risk surgery (intraperitoneal, intrathoracic, suprainguinal vascular), ischemic heart disease, heart failure, cerebrovascular disease, insulin-treated diabetes, and creatinine >2.0 mg/dL. Risk rises from about 0.4% with zero predictors to about 11% with three or more.
  • Functional capacity: ≥4 METs generally permits surgery without further cardiac testing; poor capacity plus an active cardiac condition triggers cardiology input.
  • NPO: clear fluids 2 h; breast milk 4 h; infant formula or nonhuman milk 6 h; light meal 6 h; fatty meal 8 h. The 2-4-6-8 rule is a minimum, not a target to keep patients dry.
  • Medications: continue beta-blockers, statins, and most antihypertensives; hold ACE inhibitors/ARBs on the morning of major surgery when hypotension is likely; hold SGLT2 inhibitors 3-4 days; hold GLP-1 receptor agonists per 2023 ASA guidance (daily: 1 day; weekly: 1 week), with gastric ultrasound if symptoms persist.
  • Anticoagulants: follow ASRA and cardiology timing for neuraxial and surgical procedures; do not reverse without an indication.
  • Labs and ECG are not routine; order them when history, surgery, or comorbidity would change management.

Worked example

A 68-year-old with insulin-treated diabetes, prior myocardial infarction, and planned open colectomy has three RCRI predictors (high-risk surgery, ischemic heart disease, insulin-treated diabetes), so estimated major cardiac events are high (about 11%). Useful actions are not a resting ECG alone; they include checking HbA1c and renal function, continuing beta-blocker and statin, holding an SGLT2 inhibitor if prescribed, planning glucose and hemodynamic monitoring, and documenting why surgery should not be delayed if urgent.

Traps

Counting diet-controlled diabetes as an RCRI predictor; treating NPO as nothing by mouth after midnight for clear fluids; stopping beta-blockers and causing rebound ischemia; ordering stress tests that will not change a necessary urgent operation; missing OSA and frailty because the cardiac index was normal.

Key points

  • RCRI has six predictors and stratifies major cardiac events.
  • ≥4 METs usually avoids further cardiac testing.
  • NPO follows 2-4-6-8 hours by food type.
  • Hold SGLT2 inhibitors 3-4 days and GLP-1 agents per ASA guidance.
  • Tests should change management, not merely document risk.