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Preanesthesia evaluation for noncardiac surgery

Author: BobbieJean Sweitzer, MD, FACP
Section Editor: Natalie F Holt, MD, MPH
Deputy Editor: Marianna Crowley, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Apr 2020. | This topic last updated: Feb 10, 2020.

INTRODUCTION

All patients who undergo anesthesia must have a preanesthesia evaluation by an

anesthesia clinician to assess the patient's medical conditions, perioperative risk, and
readiness for the planned procedure, and to create an anesthetic plan. This topic will
discuss the components of preanesthesia evaluation, including risk assessment and
appropriate preoperative testing.

Preoperative medical evaluation and medication management are discussed separately.

(See "Preoperative medical evaluation of the healthy adult patient" and "Perioperative
medication management".)

Preoperative evaluation and management for specific medical conditions are also discussed
separately. (See 'Conditions that increase perioperative risk' below.)

GOALS FOR PREANESTHESIA EVALUATION

Goals of preoperative evaluation are to assess the patient's medical status and ability to
tolerate anesthesia for the planned procedure, reduce the risks of anesthesia and surgery,
and to prepare the patient for the procedure. Adequate preoperative patient evaluation and
preparation may improve patient satisfaction, as well as decrease complications, delays,
cancellations, costs, and mortality [1-5].

COMPONENTS OF THE PROCESS

Components of the preanesthesia evaluation process may include the following:

● Clinical evaluation to identify comorbid conditions, allergies, and previous complications

of anesthesia

● Management and optimization of medical diseases that affect perioperative risk

● Perioperative risk assessment to inform shared decisions on alternatives for care

● Creation of a plan for anesthesia and postoperative care

● Education of patients and families about expectations surrounding anesthesia care

● Obtaining informed consent (see 'Consent and decision making' below)

● Determination of appropriateness for care in ambulatory surgical facilities or remote

locations (see "Office-based anesthesia", section on 'Patient selection')

● Providing preoperative instructions regarding medication management and fasting (see

"Perioperative medication management" and "Preoperative fasting guidelines")

● Motivating patients to stop smoking, lose weight, or commit to other preventive care

● Meeting regulatory requirements

TIMING OF PREANESTHESIA EVALUATION

The most appropriate timing for preanesthesia evaluation depends upon the general health
status of the patient, his or her relationship with other care providers, the degree of risk
associated with the planned procedure, and the urgency of the procedure. Other patient
factors (eg, language barrier, intellectual disability) may also enter into the decision on
timing, method, and location of the evaluation.

Not all patients will benefit from the same approach to preanesthesia evaluation, and
resources need to be matched with expected benefits. Healthy patients having low-risk
procedures can usually be seen on the day of the procedure immediately before anesthesia.
(See 'Healthy patients' below.)

High-risk patients or patients having high-risk procedures may require further work-up, time
for medical interventions, and intensive planning well in advance of the procedure. (See
'Conditions that increase perioperative risk' below.)

Many centers have created guidelines for screening in order to triage patients for the timing
and method of preanesthesia evaluation. Such screening optimally occurs as soon as a
procedure is considered. Screening information can be completed by the patient or family
member/guardian in person (paper or electronic version), remotely via electronic health
record tools, with web-based programs, or during a telephone interview. Suggested patient
and procedure triage criteria are shown in tables (table 1 and table 2). The form we use to
collect some of the necessary information and to start a medical history is shown in a table
(table 3).

PREANESTHESIA CLINIC

Preoperative assessment and testing clinics can provide coordinated anesthesia, surgical,
and nursing assessments, and laboratory services for patients who require assessment
before the day of surgery. In effective preoperative medicine clinics, the anesthesiologist
performs a comprehensive assessment, orders testing, intervenes to optimize comorbid
conditions, arranges for necessary consultations for optimization, provides fasting and
medication instructions, and communicates with the anesthesia clinicians who will care for
the patient. High-risk patients and patients who undergo high-risk procedures may benefit
from having informed consent for anesthesia obtained in a preanesthesia clinic, without the
time constraints of discussions on the day of surgery. (See 'Consent and decision making'
below.)

Evaluation of high-risk patients in a preoperative clinic may reduce unnecessary testing

[5,6], case cancellations [7] and delays on the day of surgery [4], and mortality [8]. In
addition, perioperative medicine clinics provide opportunities for behavioral modification
intervention (eg, smoking cessation) at a 'teachable moment' when patients may be more
receptive to change due to an upcoming surgical procedure [9].

CLINICAL EVALUATION

We agree with the American Society of Anesthesiologists (ASA) Practice Advisory for
Preanesthesia Evaluation [10] that the preanesthesia assessment should include, at a
minimum, the following:

● Patient interview
● A focused examination of the airway, lungs, and heart
● Review of pertinent medical records
● Indicated preoperative tests
● Consultations with specialists if necessary

Medical history and review of systems — The medical history includes the history of
present illness, identification of the planned procedure, past and current medical conditions,
medications and allergies, tobacco and substance abuse, past surgical history, and past
experiences and problems with anesthesia in the patient or family members. The medical
history should also include the severity and stability of the medical conditions, current or
recent exacerbations, and prior treatments or planned interventions. A prior history of
difficulty with airway management, severe postoperative nausea and vomiting, or a patient
or family history of malignant hyperthermia or pseudocholinesterase deficiency is sought.
(See "Susceptibility to malignant hyperthermia: Evaluation and management".)

A history of excessive sore throat after anesthesia, dental injury related to anesthesia, or
'requiring a small breathing tube' with previous anesthetics may indicate difficulty with airway
management. Records from previous anesthetics should be reviewed when possible and
may assist with planning for airway management (table 4).

A review of systems, including a general run-through of all organ systems, is especially

useful to uncover symptoms that may lead to establishment of previously undiagnosed
conditions. A review of records, including notes from primary care clinicians or specialists,
and test results can reveal issues the patient may not recall.

The patient's functional capacity or cardiorespiratory fitness may be the single best predictor
of perioperative risk. The patient is commonly asked to name the most strenuous activity he
or she does regularly, or has done most recently, and whether such activity causes chest
pain, dyspnea, or claudication. The inability to climb two flights of stairs or walk four blocks
predicts an increased risk of postoperative cardiopulmonary complications after major
noncardiac surgery [11,12]. Self-reported functional capacity may be inaccurate; observing
the patient climbing stairs, or assessment with a six-minute walk test can provide additional
information if inaccurate self-reporting is suspected. Use of an objective tool such as the
Duke Activity Status Index (DASI) [13] or cardiopulmonary exercise testing (CPET) are more
accurate measures of actual functional capacity and predictors of perioperative cardiac risk
compared with subjective assessments [14]. The DASI questionnaire consists of 12 items
that measure the patient's functional capacity (table 5). Calculators that tally the score and
convert the results to metabolic equivalents (METS) are available online. (See "Evaluation of
cardiac risk prior to noncardiac surgery", section on 'Initial preoperative evaluation' and
'Functional status' below and "Preoperative medical evaluation of the healthy adult patient",
section on 'Exercise capacity' and "Overview of pulmonary function testing in adults", section
on 'Six-minute walk test'.)

Dyspnea is a common patient complaint that may be caused by a variety of disease states,
including some that may confer increased perioperative risk and/or changes in
management. In many cases, the etiology of dyspnea may be categorized as pulmonary or
cardiovascular (figure 1 and table 6 and table 7). Clinical assessment and testing for
patients with dyspnea are discussed separately. (See "Approach to the patient with
dyspnea".)

Anesthesia directed physical examination — At a minimum, the preanesthetic

examination includes measurement of vital signs (blood pressure [BP], heart rate,
respiratory rate, and oxygen saturation); height and weight measurements with body mass
index calculation; auscultation of the heart and lungs (especially for irregular rhythms,
murmurs, rales, or wheezing), basic neurologic examinations; and an airway assessment
(table 4). (See "Airway management for induction of general anesthesia", section on 'Airway
assessment' and "Management of the difficult airway for general anesthesia in adults",
section on 'Recognition of the difficult airway'.)

The need to routinely measure BP in preoperative clinics has been questioned. Guidelines
in the United Kingdom suggest that preoperative clinics do not need to measure BPs in
patients being seen for elective procedures if they have documented BPs <160/100 mmHg
in the referral letter from primary care [15]. Patients often have anxiety-related elevated BPs
during the preoperative visit even without a history of hypertension. In this setting, the BP
should be repeated, medical records reviewed, or the patient asked about typical BP
readings; if necessary, the patient can be asked to measure the BP at home and report the
results. Ambulatory measurement of BP correlates with end-organ damage and predicts
cerebrovascular and cardiovascular adverse events in the nonoperative setting significantly
better than clinic measurements of BPs [16].

Patients should be assessed for loose, capped, damaged, missing, and artificial teeth, which
are at increased risk for damage during airway management. Abnormalities should be
documented and confirmed with the patient.

If regional anesthesia (ie, neuraxial anesthesia/analgesia, peripheral nerve block) is planned

or possible, the regional anesthesia site is examined to assess for potential difficulty or
infection, and any preexisting neuropathy or weakness should be documented.

RISK ASSESSMENT

Assessment of the patient's risks of anesthesia and the planned procedure is an important
component of the preanesthesia evaluation. The overall perioperative risk reflects both the
risks associated with the patient's medical conditions and the risk associated with the
planned procedure.
 ● Risk assessment informs the plan for anesthesia, including the venue for the procedure,
type of anesthesia, intraoperative monitoring, and resources required.

● An elevated risk may suggest the need for preoperative intervention, in-hospital or
inpatient care rather than ambulatory surgery, and/or enhanced postoperative
monitoring and care (eg, intensive care, postdischarge skilled nursing facility).

● Perioperative assessment of the risks of complications, mortality, and likelihood of

return to independent living is part of informed consent, and may affect shared
decisions regarding surgical and nonsurgical options for treatment.

Epidemiology of perioperative risk of complications — Perioperative complications are

a major public health issue and a significant cause of avoidable morbidity and mortality [17].
Mortality rates vary widely across hospitals and countries [18,19].

● Worldwide an estimated 300 million operations are performed each year, and
approximately one out of four patients who undergo major surgery will develop
complications [18,20]. Up to 2.5 million patients will die (1 percent risk) and 12.5 million
will have costly adverse events each year [18,21,22].

● The incidence of complications varies across procedures [23] and patient populations.
Patients at highest risk are those of advanced age with comorbid diseases having major
surgery, with a hospital mortality rate as high as 12 percent [22].

● Long-term survival is significantly reduced for those patients who have perioperative
complications, even if they survive to leave the hospital [17,24].

● The costs associated with complications after surgery are substantial. In one study
mean hospital costs were $19,​626 (119 percent) higher for patients with complications
($36,​060) compared with those without complications ($16​,434) [25].

Patient risk factors

ASA physical status — The American Society of Anesthesiologists physical status

(ASA-PS) is a classification system that defines the overall health status of the patient and is
used by anesthesiologists, surgeons, and other clinicians involved in perioperative care. An
ASA-PS rating is assigned to every patient who undergoes anesthesia (table 8). The ASA-
PS was not designed to evaluate patient risks, but it is widely used for this purpose.

ASA-PS designation is subjective, and assignments vary widely among clinicians, especially
when determined by non-anesthesiologists [26,27]. Nonetheless, a higher ASA-PS is
associated with complications, increased cost, unexpected hospital admission after
ambulatory surgery, postoperative admission to the intensive care unit, hospital length of
stay, and mortality (figure 2) [26,28-33].

ASA-PS also correlates with the Charlson Comorbidity Index and the Revised Cardiac Risk
Index (RCRI) (table 9) [26,34].

The ASA-PS is a component of some more comprehensive tools for assigning perioperative
risk. (See 'Risk assessment tools' below.)

Functional status — Several studies have shown that inability to perform average levels
of exercise (4 to 5 METs) identifies patients at risk of perioperative complications [11,35].
Functional capacity reflects the integrated responses of the pulmonary, cardiovascular,
circulatory, neuromuscular, and hematologic systems and muscle metabolism. The
assessment can range from a self-reported ability to engage in activities of daily living, to
six-minute walk tests [36-38], to objective testing of oxygen uptake with cardiopulmonary
exercise testing (CPET) [39,40]. (See "Evaluation of cardiac risk prior to noncardiac
surgery", section on 'Initial preoperative evaluation' and 'Medical history and review of
systems' above.)

Biomarkers — Plasma biomarkers, such as beta natriuretic peptide, estimated

glomerular filtration rate, and C-reactive protein (CRP) may have prognostication in
predicting which patients will develop complications after major noncardiac surgery.
Biomarkers are more highly predictive of major adverse cardiac events than for other
complications [41]. Elevated preoperative and postoperative plasma levels of CRP are
associated with postoperative delirium, suggesting that a pre-inflammatory state and
inflammatory response to surgery may be mechanisms of delirium [42].

Surgical risk — In general, intraperitoneal or intraabdominal, intrathoracic, and major

vascular procedures, as well as longer procedures, those associated with greater blood loss
and intraoperative fluid shifts, and emergency procedures are associated with higher
perioperative risk. Laparoscopic, endovascular, orthopedic, peripheral procedures, and
breast surgery usually carry lower risks.

However, there are broad variations of surgical risk within these categories. This concept
was illustrated by a study that used data from the American College of Surgeons National
Surgical Quality Improvement Program (ACS NSQIP) database to determine the risk of
perioperative adverse cardiac events (PACE), defined as cardiac arrest requiring
cardiopulmonary resuscitation or acute myocardial infarction, for three million operations that
occurred between 2010 and 2015 [27]. There was a continuum of risk across over 1800
operations analyzed, and significant differences in risk among operations within traditionally
designated low, intermediate, and high risk categories. As an example, there was a threefold
difference in risk of PACE between laparoscopic total abdominal colectomy and Whipple
procedure, both of which are considered high risk according to the RCRI. This risk
stratification model requires external validation, and may require institution specific
modification for application. Examples of the risk of PACE for selected common operations
as determined by this model are shown in a table (table 10).

Surgical risk for specific postoperative outcomes (eg, cardiac complications versus
pulmonary complications) are not equivalent. More accurate assessment of surgical risk is
best accomplished by using computer- or web-based calculators of risk such as ACS NSQIP
calculator to accurately define the procedural risk and to provide data-supported risk
assessment [27].

For several guidelines and perioperative risk assessment tools, surgical risk has been
defined according to risk of death or major adverse event, with high risk arbitrarily defined as
having a greater than 5 percent risk of complications, intermediate risk as 1 to 5 percent risk,
and low risk as less than 1 percent risk [43].

The only well-established very low-risk procedure is cataract extraction [44]. If the patient is
able to lie relatively flat, stay still, follow simple commands, and local anesthesia or
monitored anesthesia care is planned, then there are few if any contraindications for
cataract surgery. There is a probably small, irreducible risk of unfavorable outcomes after
cataract surgery, given the population of older adult individuals who often have advanced
diseases.

Risk assessment tools — A number of tools have been developed that combine patient
and surgical factors to improve the accuracy of prediction of perioperative risk.

● The ACS NSQIP calculator is a free of charge online resource for overall risk
assessment that combines procedure-specific surgical risk with 20 patient factors [45].
The tool calculates risks of 15 separate outcomes, which are displayed in graphic form,
with comparison to risk for an average patient. An example of a report generated by the
ACS NSQIP calculator is shown in a figure (figure 3). Results can be easily understood
by practitioners and patients and may help with shared decision-making, especially
regarding specific risks that may be more meaningful to individual patients. For
example, older patients are typically less concerned about death than about a
degradation of quality of life or an inability to live independently [46]. Use of the results
of the NSQUIP calculator as part of informed consent is discussed below. (See
'Consent and decision making' below.)

The ACS NSQIP calculator is based on data from hospitals participating in NSQIP and
has not been validated externally. In addition, accuracy of risk estimates may be uneven
across outcome measures, and the calculator may be less useful for some categories of
procedures than others [47-50].

● Risk calculators specifically for cardiovascular complications include the Gupta

Perioperative Risk for Myocardial Infarction or Cardiac Arrest (MICA) calculator, and the
RCRI (table 9). These tools and their use in evaluating preoperative cardiac risk, and
the use of the American College of Cardiology/American Heart Association guideline on
perioperative cardiovascular evaluation and management of patients undergoing
noncardiac surgery, are discussed separately. (See "Evaluation of cardiac risk prior to
noncardiac surgery", section on 'Risk assessment'.)

● A simple risk score has been developed for predicting 30-day mortality after noncardiac
surgery using data from the ACS NSQIP database [51]. Three elements, ASA PS
status, surgery risk, and whether the procedure is performed on an emergency basis,
 are scored and assigned points. The scoring system and associated mortality are
shown in a table (table 11).

● The Society of Neuroscience in Anesthesiology and Critical Care published consensus

guidelines for risk assessment and reduction for perioperative stroke in noncardiac and
non-neurological surgery [52]. These guidelines address optimal timing of surgery after
stroke, risk factors for postoperative stroke, appropriate use of antiplatelet agents, and
bridging anticoagulation [52].

● Risk calculators have been developed to estimate the risk of postoperative respiratory
failure or pneumonia. Some have used the ACS NSQIP data to create these [53,54].
Established risk factors for broader pulmonary complications include a history of
cigarette use (current or exceeding 40 pack-years); ASA-PS ≥2; age ≥70 years; chronic
obstructive pulmonary disease; neck, thoracic, upper abdominal, aortic, or neurologic
surgery; procedures ≥2 hours; planned general anesthesia (especially with
endotracheal intubation); albumin concentration <3g/dL; inability to walk two blocks or
climb one flight of stairs; or a body mass index ≥30 [53,55-58]. (See "Evaluation of
preoperative pulmonary risk", section on 'Estimating postoperative pulmonary risk'.)

HEALTHY PATIENTS

Patients who are <65 years of age, who are determined to be healthy or to have stable,
adequately treated medical conditions on preoperative screening, and who are having low-
risk surgery can usually be evaluated by the anesthesia clinician on the day of surgery.
Exceptions to this rule are shown in a table (table 1). These patients generally do not require
routine testing. (See 'Preoperative testing' below.)

Healthy patients who are scheduled to undergo high-risk surgery should be evaluated in
advance of surgery to allow adequate time for testing and patient preparation.

CONDITIONS THAT INCREASE PERIOPERATIVE RISK

Some medical conditions are associated with increased perioperative risk. Patients with
these conditions may require more extensive preanesthesia evaluation and/or testing.

Advanced age — Older adults have a higher risk for perioperative complications than
younger patients, primarily as a result of comorbidities. After adjusting for comorbidities, the
impact of age on perioperative outcomes is somewhat mitigated. A checklist for preoperative
assessment of geriatric patients is shown in a table (table 12). Particular concerns that apply
to the preoperative evaluation of older patients include the following:

● Frailty – Frailty is defined as a decrease in physiologic reserve that exceeds what might
be expected from advanced age alone, and is associated with increased morbidity and
mortality. All patients older than 65 years of age having major surgery should be
screened for frailty (table 13). Frailty is a stronger predictor than age of adverse
outcomes. Nursing home residents are at particularly high risk of death and further
functional decline even with minor surgeries [59]. (See "Anesthesia for the older adult",
section on 'Frailty'.)

● Treatment goals – The risks of surgery, likelihood of the patient returning to baseline
functional status, and advance directives should be reviewed with all patients and are
particularly important for older patients.

● Cognitive dysfunction – Impaired cognition and dementia are common and are often
unrecognized in older adults. Preoperative cognitive dysfunction is the strongest
predictor of postoperative delirium, neurocognitive disorders, and cognitive decline [60-
65]. Other risk factors include advanced age and lower educational achievement. Using
a basic cognitive screening tool such as the Mini-Cog (freely available through the
Alzheimer's Association) to screen patients preoperatively can assist with decisions and
planning. (See "Perioperative neurocognitive disorders".)

● History of falls – Patients who have fallen three or more times in the six months
preceding major surgery have a 100 percent chance of a perioperative complication
[66].

● Activities of daily living – Patients who are dependent or partially dependent on

others to assist with bathing, feeding, and dressing have higher risks of adverse events
 when having surgery [67].

● Medications – Medication reconciliation is an important aspect of preoperative

assessment and may be difficult in older adults who are taking multiple medications.
(See "Anesthesia for the older adult", section on 'Medication history'.)

● Preoperative testing – There is no consensus on the specifics of routine testing in

older patients. We recommend measuring hemoglobin (Hg), creatinine, and albumin
preoperatively for patients >65 years of age who undergo moderate or high-risk surgery
because of the relatively high incidence of anemia, renal dysfunction, and malnutrition
in these patients [68].

Criteria for other preoperative laboratory testing, electrocardiogram (ECG), and chest
radiograph should be based on comorbidities, rather than on age alone [68]. (See
"Perioperative blood management: Strategies to minimize transfusions", section on
'Selective laboratory testing' and 'Preoperative testing' below.)

Cardiovascular disease

● Hypertension – Hypertension is associated with an increased risk of perioperative

cardiovascular complications, but it is not clear that preoperative normalization of blood
pressure (BP) reduces perioperative risk. Hypertension over time is associated with
cardiovascular complications that may increase perioperative risk, including diastolic
dysfunction, heart failure (HF), renal impairment, cerebrovascular disease, and
coronary artery disease (CAD). (See "Perioperative management of hypertension",
section on 'Perioperative risks associated with hypertension' and "Anesthesia for
patients with hypertension".)

There is little evidence for an association between perioperative complications and

preoperative BP <180 mmHg systolic or 110 mmHg diastolic [69].

The optimal BP level that should be achieved in anticipation of elective surgery is

unclear. For most patients, we agree with the Joint Guidelines from the Association of
Anaesthetists of Great Britain and Ireland and the British Hypertension Society on the
preoperative measurement and management of hypertension, which state that primary
 care practices should aim to control BPs to <160/100 before referral for elective surgery,
but that if BPs are not known then surgery can proceed in patients with measurements
<180 mmHg systolic and 110 mmHg diastolic in the preoperative clinic or on the day of
surgery [15]. The decision to delay surgery for BP optimization or institute new
antihypertensive treatment must be individualized, based on patient factors and the
urgency of surgery. Regardless of BP on the day of surgery, if patients have taken their
BP medications, are asymptomatic, and there is evidence that the patient's BPs before
the day of surgery are usually <160/100, then proceeding with planned anesthesia is
acceptable.

Most antihypertensive agents can be continued up to and including the day of surgery,
with the likely exception of angiotensin-converting enzyme (ACE) inhibitors and
angiotensin II receptor blockers (ARBs). ACE inhibitors and ARBs may increase the
incidence of hypotension during anesthesia and morbidity and mortality during major
surgery [70]. (See "Perioperative management of hypertension", section on
'Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers' and
"Perioperative medication management", section on 'ACE inhibitors and angiotensin II
receptor blockers'.)

● Heart failure – Patients with HF have a significantly higher risk of postoperative death
than patients with coronary artery disease. Whenever possible, surgery should be
delayed in patients with decompensated HF. HF is an important risk factor in the risk
stratification models for preoperative assessment. (See 'Risk assessment tools' above.)

Decisions on whether and when to proceed with surgery, preoperative assessment, and
preoperative medical management should reflect the urgency of the surgery, the
stability of the patient's HF, and the possible therapeutic alternatives. Strategies for
preoperative assessment, decision making regarding the timing of surgery, and
perioperative management of patients with HF are discussed separately, and are shown
in algorithms (algorithm 1 and algorithm 2). (See "Perioperative management of heart
failure in patients undergoing noncardiac surgery".)

Preoperative testing for patients with HF is based on the likelihood that testing will
change perioperative management or the decision to proceed with surgery. Indications
 for electrocardiogram, transthoracic echocardiogram, chest radiograph, and natriuretic
peptide levels, and exercise testing are discussed separately. Measurement of beta
natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP) is useful in patients with
suspected HF or to guide optimization. BNP or NT-proBNP levels can identify patients
at increased risk for major adverse cardiac events [71]. (See "Perioperative
management of heart failure in patients undergoing noncardiac surgery", section on
'Preoperative tests'.)

● Undiagnosed murmurs – Systolic murmurs may be the most common incidental

finding during a cardiac physical examination. The differential diagnoses include aortic
stenosis or sclerosis, mitral or tricuspid regurgitation, hypertrophic cardiomyopathy and
hyperdynamic states secondary to infection, fever, thyrotoxicosis, and pregnancy.
Patients with undiagnosed murmurs require an ECG and a careful history. Any
abnormality on an ECG in patients with murmurs, symptoms of dyspnea, chest pain,
syncope or near-syncope in patients with murmurs, and murmurs in individuals >50
years of age warrant an echocardiogram. (See 'Cardiac testing' below.)

Diastolic murmurs are always pathologic and warrant further evaluation. Mitral stenosis
(MS) and aortic insufficiency are the most common causes with the former posing a
significant perioperative risk if more than mild.

● Valvular heart disease – Stenotic cardiac valvular diseases (ie, aortic stenosis [AS]
and MS) are associated with an increased risk of perioperative complications. Risks of
anesthesia and surgery can be minimized by an accurate diagnosis of type and severity
of disease, planning the appropriate anesthetic, instituting a higher level of monitoring
(such as an arterial line, transesophageal echocardiography [TEE], or pulmonary artery
catheter), changing venue for the procedure (for example, not an ambulatory surgical
center), and managing postoperatively in an intensive care unit [72]. Patients with
known or suspected moderate or severe valvular disease should undergo preoperative
echocardiography if there has been no echocardiogram within one year, or if there has
been a significant change in physical examination or clinical status since the last
evaluation (table 14) [73].

• AS is a common valvular lesion that increases in frequency with age and is

 associated with coronary artery disease. The preoperative evaluation and risk
assessment for patients with AS, and indications for intervention, are discussed
separately (table 15). (See "Noncardiac surgery in patients with aortic stenosis".)

• Severe asymptomatic and untreated symptomatic MS are associated with high

perioperative risk. Preoperative evaluation and indications for intervention are
discussed separately (table 16). (See "Overview of the management of mitral
stenosis", section on 'Noncardiac surgery'.)

• Regurgitant valvular lesions (ie, aortic regurgitation [AR] or mitral regurgitation

[MR]) are typically better tolerated perioperatively than stenotic lesions.
Preoperative risk assessment and evaluation are discussed separately. (See
"Noncardiac surgery in patients with mitral or aortic regurgitation".)

• Patients with mechanical heart valves are usually maintained on anticoagulants.

For most procedures, other than cataract surgery, these drugs are stopped
preoperatively based on the half-life of the drug to allow normalization of
coagulation parameters. Interruption of anticoagulation is usually coordinated with
the patient's cardiologist. Perioperative management of anticoagulants is discussed
separately. (See "Perioperative management of patients receiving anticoagulants".)

● Arrhythmias – The perioperative risk associated with some arrhythmias (eg,

supraventricular tachycardia, asymptomatic ventricular arrhythmias) is unclear [72].
However, some arrhythmias, including symptomatic bradycardia, symptomatic
ventricular arrhythmias, Mobitz II, and third-degree heart block all increase perioperative
risk [72], and may be associated with underlying cardiac disease [74]. Patients with
Mobitz II and complete heart block need to have all except emergency surgery delayed
for further evaluation and likely pacemaker insertion. (See "The preoperative ECG:
Evaluation and implications for anesthetic management".)

Clinically stable patients with atrial fibrillation (AF) are at elevated risk of perioperative
complications but generally do not require special evaluation or a change in medical
management unless there is a rapid ventricular rate, but may require modification of
anticoagulation. (See "Perioperative management of patients receiving anticoagulants",
 section on 'Atrial fibrillation'.)

If AF is newly identified on a preoperative electrocardiogram or by physical examination,

nonemergency surgery is usually delayed for evaluation. If necessary, an urgent
cardiology consultation can be requested with a multidisciplinary discussion of the risks
and benefits of proceeding with surgery. It may be reasonable to proceed with minor
procedures, such as cataract surgery or colonoscopy, especially under monitored
anesthesia care in patients with newly discovered preoperative AF as long as the
patient has a controlled rate (ie, less than 100 beats per minute) and adequate blood
pressure. These patients require expedited referral for evaluation and management of
their AF. (See "New onset atrial fibrillation" and "Atrial fibrillation in patients undergoing
noncardiac surgery", section on 'Patients with newly discovered atrial fibrillation'.)

● Coronary artery disease – Coronary artery disease (CAD) is a risk factor for
perioperative myocardial ischemia and infarction and death. CAD varies from a mild,
stable disease with little impact on perioperative outcome, to severe disease that
accounts for serious complications during anesthesia. A goal for preoperative evaluation
is to identify a small subset of patients who have unstable or severe enough CAD that
the planned surgical procedure will pose a significant risk. Even patients with significant
CAD have a low risk when having low-risk surgeries [72,75]. An algorithm for
preoperative cardiac risk assessment for patients with risk factors for CAD is provided
(algorithm 3).

Preoperative cardiac risk assessment, including evaluation for CAD, and management
of cardiac risk, are discussed separately. (See "Evaluation of cardiac risk prior to
noncardiac surgery" and "Management of cardiac risk for noncardiac surgery" and
"Noncardiac surgery after percutaneous coronary intervention".)

Preoperative coronary revascularization (ie, coronary artery bypass grafting and/or

percutaneous coronary intervention) is discussed separately. (See "Management of
cardiac risk for noncardiac surgery", section on 'Revascularization before surgery'.)

● Cardiac implantable electronic devices – Patients with pacemakers and implantable

cardioverter defibrillators (ICDs) are often older adults, and may have HF, ischemic or
 valvular disease, cardiomyopathies, or potentially lethal arrhythmias that increase
perioperative risk. Pacemakers and ICDs can be affected by intraoperative interference;
a systematic approach to the perioperative evaluation and management of these
devices is required, and is discussed separately. (See "Perioperative management of
patients with a pacemaker or implantable cardioverter-defibrillator".)

Cerebrovascular disease — Individuals with cerebrovascular disease are at increased risk

of CV and cerebrovascular events in the perioperative period [72,76]. The presence of
cerebrovascular disease is often a marker for coexisting cardiovascular disease [77], and a
stroke or transient ischemic attack (TIA) is a risk factor equivalent to known chronic coronary
syndrome, also referred to as stable ischemic heart disease, in the Revised Cardiac Risk
Index (RCRI). (See 'Risk assessment tools' above.)

The timing of surgery should be considered and elective surgery should be deferred in
patients with recent stroke. Timing of surgery for patients with a history of stroke, the risk of
perioperative stroke, and management of asymptomatic carotid bruits are discussed
separately. (See "Perioperative stroke following noncardiac, nonneurologic surgery", section
on 'Patient risk factors'.)

Neurologic disease — A number of neurologic diseases increase perioperative risk or

require specific perioperative evaluation and management. These issues are discussed
separately. (See "Perioperative care of the surgical patient with neurologic disease".)

Pulmonary disease — Postoperative pulmonary complications contribute significantly to

overall perioperative morbidity and mortality. Estimation of pulmonary risk is a standard
element of all preoperative medical evaluations. Preoperative evaluation of pulmonary risk,
including pulmonary function testing, the risks associated with pulmonary hypertension, and
strategies to prevent pulmonary complications, are discussed separately. (See "Evaluation
of preoperative pulmonary risk" and "Strategies to reduce postoperative pulmonary
complications in adults" and "Anesthesia for patients with chronic obstructive pulmonary
disease", section on 'Preanesthesia consultation'.)

Specialized testing, including cardiopulmonary exercise test and the six-minute walk test,
are discussed separately. (See "Evaluation of preoperative pulmonary risk", section on
'Exercise testing' and "Overview of pulmonary function testing in adults", section on 'Six-
minute walk test'.)

Obstructive sleep apnea — Patients with obstructive sleep apnea (OSA) are at increased
risk of perioperative complications. Surgical risk, preoperative evaluation, and anesthetic
management of patients with OSA are discussed separately. (See "Surgical risk and the
preoperative evaluation and management of adults with obstructive sleep apnea" and
"Intraoperative management of adults with obstructive sleep apnea".)

Kidney disease — Chronic kidney disease is associated with cardiovascular disease, and
increases the risk of postoperative morbidity and mortality [78,79]. Chronic kidney disease
(CKD) is a factor in several risk scores, including the RCRI and the Myocardial Infarction or
Cardiac Arrest (MICA) cardiac risk calculator. (See "Overview of the management of chronic
kidney disease in adults", section on 'Association with cardiovascular disease, end-stage
renal disease, and mortality' and "Evaluation of cardiac risk prior to noncardiac surgery",
section on 'Revised cardiac risk index'.)

The strongest predictor of postoperative kidney dysfunction is preoperative kidney disease

[80]. We measure creatinine preoperatively if CKD is known or suspected, the patient is >65
years of age planning intermediate to high risk surgery, or if the use of intravenous contrast
dye is planned. Serum electrolytes should also be measured in patients with CKD.

Patients with end-stage kidney disease on dialysis have a high incidence of other
comorbidities and are at increased risk of perioperative complications. Preanesthesia
evaluation and anesthetic management of patients on dialysis are discussed separately.
(See "Anesthesia for dialysis patients".)

Liver disease — Severe liver disease increases perioperative risk, especially with major
surgery. Preoperative evaluation, including preoperative laboratory evaluation, and
assessment of perioperative risk in patients with liver disease, are discussed separately.
(See "Anesthesia for the patient with liver disease", section on 'Preoperative evaluation for
patients with known liver disease' and "Assessing surgical risk in patients with liver
disease".)
Endocrine disease

● Diabetes – Diabetes mellitus is associated with increased risk of perioperative infection

and postoperative cardiovascular morbidity and mortality [72,81-83]. Diabetes mellitus
is associated with multisystem complications that may also affect perioperative
management. Preoperative assessment and perioperative management of blood
glucose in these patients are discussed separately. (See "Perioperative management of
blood glucose in adults with diabetes mellitus" and "Overview of general medical care in
nonpregnant adults with diabetes mellitus" and "Anesthesia for patients with diabetes
mellitus".)

Long-term diabetic control, reflected in hemoglobin (Hg) A1c levels is likely much more
important than a random blood glucose performed on the day of surgery. HgA1c
predicts perioperative blood glucose levels [84], and elevated A1C may predict a higher
rate of postoperative adverse events, including infection, myocardial infarction, and
mortality. (See "Perioperative management of blood glucose in adults with diabetes
mellitus", section on 'Laboratory'.)

Poorly controlled diabetes is associated with increased surgical site infections. Optimal
blood glucose targets have not been determined, but for some procedures (eg, joint
replacement or major spine surgeries) surgeons have established absolute A1C cutoffs for
performing elective surgery (eg, <8 percent). (See "Susceptibility to infections in persons
with diabetes mellitus", section on 'Risk of infection'.)

● Thyroid disease – Significant hyper- or hypothyroidism may increase perioperative risk

[85]. Preoperative evaluation and anesthetic management for patients with thyroid
disease are discussed separately. (See "Anesthesia for patients with thyroid disease
and for patients who undergo thyroid or parathyroid surgery".)

● Adrenal disorders – Patients with Cushing's disease and adrenal insufficiency require
management to lower perioperative risk. (See "Treatment of adrenal insufficiency in
adults" and "Overview of the treatment of Cushing's syndrome".)

Patients with pheochromocytoma are at high risk of hemodynamic instability and

 arrhythmias during surgery. Preoperative evaluation and preparation of these patients
are discussed separately. (See "Anesthesia for the adult with pheochromocytoma" and
"Anesthesia for the adult with pheochromocytoma", section on 'Preoperative
evaluation'.)

Patients who have been taking glucocorticoid medication are at risk for adrenal
insufficiency in the perioperative period. Perioperative management of these patients is
discussed separately. (See "The management of the surgical patient taking
glucocorticoids".)

● Pituitary abnormalities – Pituitary abnormalities can cause hormonal hyposecretion or

hypersecretion that may increase perioperative risk. As examples, both acromegaly and
Cushing's syndrome increase the risk of difficulty with airway management [86], and are
associated with cardiovascular disease and obstructive sleep apnea. (See "Causes and
clinical manifestations of acromegaly", section on 'Sleep apnea' and "Epidemiology and
clinical manifestations of Cushing's syndrome", section on 'Cardiovascular' and "Causes
and clinical manifestations of acromegaly", section on 'Cardiovascular disease'.)

Anemia — Anemia is present in 5 to 7 percent of elective surgical patients, depending on

associated comorbidities and age [87]. Preoperative anemia, even when mild, is associated
with increased 30-day mortality after major noncardiac surgery [88-90], and also increases
need for perioperative transfusions. When hemoglobin testing is indicated, it should be done
early enough to allow time for diagnosis and treatment of the causes of anemia or
hemostatic abnormalities. Elective surgery is best delayed to allow time to identify and
potentially correct abnormalities (algorithm 4). (See "Perioperative blood management:
Strategies to minimize transfusions", section on 'Preoperative strategies' and 'Preoperative
testing' below and "Approach to the adult with anemia".)

Patients with sickle cell disease are at risk of perioperative complications, some of which
may be ameliorated by modifications in management. Perioperative management of these
patients, including preoperative transfusion and control of acute pain, are discussed
separately. (See "Red blood cell transfusion in sickle cell disease", section on 'Prophylactic
preoperative transfusion' and "Acute vaso-occlusive pain management in sickle cell
disease", section on 'Overview of acute pain management'.)
Perioperative concerns for patients with thalassemia, including anemia, skeletal
abnormalities, and possible cardiac or hepatic complications, are discussed separately. (See
"Management and prognosis of the thalassemias", section on 'Surgery/anesthesia
concerns'.)

Malnutrition — Malnutrition is a strong predictor of perioperative mortality and morbidity,

longer length of stay postoperatively, higher readmission rates, and increased costs of care
[91]. It is estimated that 50 percent or more of older adult patients having major surgery are
undernourished [92]. We screen patients for malnutrition, and send the following categories
of patients for evaluation in a nutrition clinic or dietician intervention prior to surgery:

● BMI <18 kg/m2 (<20 kg/m2 for patients >65 years of age)
● Unplanned weight loss >10 percent of body weight in past six months
● Patient has eaten <50 percent of his/her normal diet in the preceding week

Patients screened as nutritionally at risk before major surgery may benefit from preoperative
oral nutritional supplements with a minimum of 18 g protein two to three times per day for 7
to 14 days [93].

Thromboembolic disorders — Venous thromboembolism (VTE; deep venous thrombosis

and pulmonary embolism) is common among surgical inpatients in the postoperative setting,
and pulmonary embolism is one of the most common preventable causes of in-hospital
deaths following surgery. Traditionally ambulatory surgeries were thought to have a very low
risk of VTE, but with the increasing complexity of procedures being done on an outpatient
basis, some patients with multiple risk factors are at similar risk to lower risk inpatients [94].
Assessment of the risk of VTE, including inherited and acquired hypercoagulable states, and
strategies for prevention are discussed separately. (See "Prevention of venous
thromboembolic disease in adult nonorthopedic surgical patients" and "Prevention of venous
thromboembolism in adult orthopedic surgical patients" and "Overview of the causes of
venous thrombosis".)

Patients who are chronically at increased risk of thromboembolism (ie, atrial fibrillation [AF],
prosthetic heart valves, and recent or previous thromboembolic events) may require
interruption of anticoagulation or perioperative bridging strategies. Perioperative
management of these patients is discussed separately. Patients with recent arterial or VTE
should have all except emergency surgery delayed for a minimum of 30 days and ideally
should complete a three month course of uninterrupted anticoagulant therapy. (See
"Perioperative management of patients receiving anticoagulants".)

Obesity — With the exception of thromboembolism and peripheral nerve injuries, obesity
itself is not associated with an increased risk of adverse outcomes after noncardiac surgery
and is not a factor in preoperative risk screening tools. (See "Preanesthesia medical
evaluation of the obese patient", section on 'Perioperative risks in obese patients' and
"Preoperative medical evaluation of the healthy adult patient", section on 'Obesity'.)

However, obesity is associated with difficulty with airway management, and with a number of
comorbidities that increase perioperative risk, including obstructive sleep apnea, heart
disease, hypertension, and diabetes mellitus. (See "Preanesthesia medical evaluation of the
obese patient", section on 'Preoperative evaluation'.)

Tobacco use — Exposure to tobacco, directly or through second-hand smoke, increases

the risk of many perioperative complications [95-97]. The benefits and optimal duration of
smoking cessation are discussed separately. Preoperative clinics play an important role in
discussing the benefits of smoking cessation and offering patients both pharmacologic and
non-pharmacologic interventions. (See "Strategies to reduce postoperative pulmonary
complications in adults", section on 'Smoking cessation' and "Preoperative medical
evaluation of the healthy adult patient", section on 'Smoking'.)

Alcohol misuse — Patients who misuse alcohol on a regular basis have an increased risk
of postoperative complications. (See "Preoperative medical evaluation of the healthy adult
patient", section on 'Alcohol misuse'.)

PREOPERATIVE TESTING

Preoperative testing should be performed selectively, based on the patient's medical status,
the planned procedure, and the likelihood that test results will change management or help
with risk assessment (table 17). We agree with a practice advisory from the American
Society of Anesthesiologists (ASA) [10], the Choosing Wisely initiative [98], and a safety
guideline from the Association of Anaesthetists of Great Britain and Ireland [99], which
recommend against routine preoperative laboratory testing in the absence of clinical
indication.

Selective testing — The rationale for selective testing and predictive value of preoperative
laboratory testing are discussed separately. (See "Preoperative medical evaluation of the
healthy adult patient", section on 'Laboratory evaluation'.)

● For most low-risk procedures, no testing is indicated unless the patient has a new,
unstable, or worsening condition.

● For intermediate- to high-risk surgeries, testing is indicated based on patient

comorbidities when the results will change management or risk assessment.

● Testing is also based on the type of surgery (eg, expected blood loss or the use of
contrast dye).

Specific preoperative laboratory tests are discussed separately. (See "Preoperative medical
evaluation of the healthy adult patient", section on 'Laboratory evaluation'.)

Our recommendations for basic testing, and for testing for patients with suspected
conditions who will undergo intermediate- to high-risk procedures are shown in tables (table
18 and table 19). These tests may not have added value for patients undergoing low-risk
procedures and do not benefit patients having cataract surgery [100].

Blood type and screen and cross match — A blood type and screen is ordered whenever
there is an anticipated need for a blood transfusion [101]. Patients with known red blood cell
(RBC) antibodies or with an elevated risk due to a history of transfusions or pregnancy
should have a type and screen performed ahead of the day of surgery if there is even a
moderate risk of bleeding. Significant or multiple RBC antibodies can present difficulties with
finding compatible blood. Type and screen must be performed within three days of
transfusion for patients who have been pregnant in the previous three months (or are
currently pregnant), who have received a transfusion in the past three months, or in whom
the pregnancy status or transfusion history is unknown. Otherwise, a type and screen is
good indefinitely per FDA rules, though most institutions arbitrarily set expiration dates.
Patients who have been transfused or pregnant at any time are at risk of having red cell
antibodies, which can pose challenges for availability of compatible cross-matched blood
[101]. Information from a type and screen before the day of surgery can allow the blood
bank adequate time to obtain blood. (See "Pretransfusion testing for red blood cell
transfusion", section on 'Specimen requirements'.)

Blood type and cross match should be based on the expectation of blood loss. Most
crossmatching is now electronic (as long as no RBC antibodies are present) and can be
done within a matter of minutes. Using a maximum surgical blood order schedule or
surgeon/procedure-specific data can optimize efficient testing and preparation of available
blood products [102-104]. A type and cross match always expires within three days.

Pregnancy testing — Pregnancy testing on the day of surgery should be offered to female
patients capable of having children (table 19). Pregnancy is excluded before gynecologic
surgery in women of reproductive age, either by the use of a screening checklist (table 20)
or by pregnancy testing. Women should have the right to refuse testing after a discussion of
the potential risks associated with anesthesia, surgery, and pregnancy.

Routine preoperative pregnancy testing is controversial. Guidelines in the United Kingdom

[105,106] and from the ASA [10] recommend offering pregnancy testing to women in whom
pregnancy is possible, but some institutions go further and require pregnancy testing for all
reproductive age women before anesthesia. We offer pregnancy testing to women who
could be pregnant, after a discussion of the potential risks associated with anesthesia,
surgery, and pregnancy, but give them the option to refuse testing.

Patients who could be pregnant should understand that pregnancy may change
perioperative management. The patient might elect to cancel elective surgery or choose an
alternative treatment approach. In addition, anesthetic technique may be changed, and there
may be risks to the fetus if a pregnancy is undetected before surgery and anesthesia. (See
"Anesthesia for nonobstetric surgery during pregnancy", section on 'Effects of anesthetics on
the fetus and the pregnancy'.)

Testing ahead of the day of surgery should be performed if pregnancy is suspected.

However, routine screening for pregnancy is best done on the day of the surgery. (See
"Overview of preoperative evaluation and preparation for gynecologic surgery", section on
'Pregnancy test'.)

Cardiac testing — Stress testing is rarely useful solely because of surgery, without other
indications. Although there is a clear relationship between the degree of myocardial
ischemia found on testing and prognosis, there is no evidence that prophylactic
revascularization only to prevent ischemia at the time of surgery improves outcomes. In
addition, stress testing can lead to further invasive procedures with attendant risks (eg,
cardiac catheterization, percutaneous intervention, revascularization, radiation exposure,
and delay of surgery), without proven benefit.

However, some experts recommend preoperative stress imaging in patients who are
scheduled for major vascular surgery. (See "Evaluation of cardiac risk prior to noncardiac
surgery", section on 'Further cardiac testing'.)

Preoperative cardiac evaluation and testing may differ for patients being evaluated for liver
or kidney transplant. (See "Liver transplantation in adults: Patient selection and
pretransplantation evaluation", section on 'Cardiac stress testing' and "Kidney
transplantation in adults: Evaluation of the potential kidney transplant recipient", section on
'Coronary heart disease'.)

Patients who present preoperatively with unevaluated symptoms consistent with ischemia
may meet criteria for evaluation with stress testing [72]. In this case, the urgency of surgery
factors into the decision on the type of testing performed. (See "Selecting the optimal
cardiac stress test".)

The details of a preoperative positive stress test are as important as simply the fact that it
shows ischemia, especially for patients with an established diagnosis of coronary artery
disease (CAD). Large areas of stress-induced wall motion abnormalities on dobutamine
stress echocardiography or poor exercise capacity on cardiopulmonary exercise testing
(CPET) predict elevated risk [107,108], whereas fixed defects do not predict increased risk
[72].
A resting echocardiogram is warranted in patients with undiagnosed murmurs and
symptoms of dyspnea, chest pain, syncope or near-syncope, those with undiagnosed
murmurs and an abnormal electrocardiogram (ECG), and murmurs in individuals >50 years
of age. (See 'Cardiovascular disease' above and "Evaluation of cardiac risk prior to
noncardiac surgery", section on 'Resting echocardiography'.)

Preoperative ECGs, chest radiographs, and pulmonary function testing are discussed
separately. (See "Preoperative medical evaluation of the healthy adult patient", section on
'Electrocardiogram' and "Evaluation of preoperative pulmonary risk", section on 'Pulmonary
function testing' and "Evaluation of preoperative pulmonary risk", section on 'Chest
radiographs'.)

MEDICATION MANAGEMENT

The principles of perioperative medication management, and the management of common

medications known to interact with anesthetic agents are discussed in detail separately.
(See "Perioperative medication management".)

POSTOPERATIVE PLANNING

High-risk patients are best managed in intensive care units immediately postoperatively, with
protocol-based care with careful attention to management of pain, hemodynamics,
pulmonary toilet, and early interventions [18,109]. Arrangements for postoperative intensive
care are often initiated during the preoperative evaluation session.

The plan for postoperative care is discussed in the UpToDate topics on anesthesia for
specific surgical procedures and for patients with specific comorbidities.

CONSENT AND DECISION MAKING

Informed consent is obtained for anesthetic care and is based on the principle of patient
autonomy (ie, the patients' right to be involved in decisions that affect them). In our
experience, discussing options for upcoming anesthesia can lower anxiety and improve
patient satisfaction.

Most patients want to be made aware of findings from their preoperative evaluation, be
informed of risks, and be involved in decisions about their care. The results of risk
assessment tools can be used as part of shared decision making and informed consent. In a
single center study that evaluated sharing the results of the American College of Surgeons
National Surgical Quality Improvement Program (ACS NSQIP) calculator with patients,
patient perceptions of the experience were favorable; 93 percent of patients said the results
improved their understanding of their risks and 81 percent stated that they would want to
know the details of risk before consenting to surgery [110]. Overall, patients tended to
overestimate their risks of surgery, though high-risk patients tended to underestimate their
risks. Knowledge of personal risk decreased preoperative anxiety in 70 percent of patients,
and had no effect on anxiety in 20 percent. The majority of patients were willing to undergo
prehabilitation if it would reduce their risks of complications.

The following table outlines important components of patient preparation for shared
decisions regarding their anticipated anesthesia (table 21) [111,112]. Patients need to be
informed of the more common risks and, when appropriate, of complications that rarely
occur after certain procedures but would have major impact (eg, postoperative visual loss
associated with prone positioning for spine surgery). Complex discussions ideally occur
before the day of surgery, with adequate time to address all questions.

Informed consent for medical procedures is discussed in detail separately. (See "Informed
procedural consent".)

Patients with do not resuscitate (DNR) orders should not be denied anesthesia and
procedural care simply because of their DNR status [113]. Whenever possible, the
anesthesia clinician should involve the patient, family members, and surrogates, as
appropriate, in detailed discussion of the patient's values and preferences with respect to
resuscitation. Some aspects of anesthesia care necessarily involve procedures that in other
circumstances would be considered resuscitation (eg, endotracheal intubation). The
patient's acceptance of specific procedures and levels of resuscitation (eg, pharmacologic
reversal of hypotension related to anesthetic medication) should be determined and
documented. The plan for postoperative reinstatement of any existing directives is
determined and documented.

The Association of Anaesthetists of Great Britain and Ireland has created guidelines for
consent for anesthesia [114], whereas the American Society of Anesthesiologists (ASA) has
not.

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Preoperative
medical evaluation and risk assessment".)

SUMMARY AND RECOMMENDATIONS

● All patients who undergo anesthesia must have a preanesthesia evaluation by an

anesthesia clinician to assess the patient's perioperative risk and readiness for the
planned procedure, and to create an anesthetic plan.

● The goals of preoperative evaluation are to assess the patient's medical status and
ability to tolerate anesthesia for the planned procedure, reduce the risks of anesthesia
and surgery, and to prepare the patient for the procedure. (See 'Goals for preanesthesia
evaluation' above.)

● Components of the preanesthesia evaluation process include clinical evaluation, risk

assessment, optimization of medical diseases that affect perioperative risk, patient
education and informed consent, and creation of a plan for anesthesia and
postoperative care. (See 'Components of the process' above.)

● Healthy patients having low-risk procedures can be evaluated on the day of the
procedure immediately before anesthesia. High-risk patients or those planning high-risk
procedures may require testing, time for medical interventions, intensive planning, and
may therefore benefit from assessment well in advance of the procedure. (See 'Timing
 of preanesthesia evaluation' above.)

● Patients should be assessed with a medical history and anesthesia-directed physical

examination, including an airway assessment. (See 'Clinical evaluation' above.)

● Assessment of the patient's risks of anesthesia and the planned procedure informs the
plan for anesthesia, may suggest the need for preoperative intervention and
perioperative care, and may affect shared decisions regarding surgical and alternative
options for treatment. (See 'Risk assessment' above.)

• Patients are assigned an American Society of Anesthesiologists Physical Status

(ASA-PS) class in anticipation of anesthesia. Patient factors, including
comorbidities and functional status, affect the patient's predicted risk. (See 'Patient
risk factors' above.)

• Surgical procedures are classified as high, intermediate, or low risk. Cataract

surgery is considered a very low-risk procedure. (See 'Surgical risk' above.)

• Risk assessment tools that include patient and surgical risk factors may be used to
predict perioperative risks of cardiac and pulmonary adverse events and
perioperative mortality. (See 'Risk assessment tools' above.)

● Patients with conditions that increase perioperative risk may require more extensive
preanesthesia evaluation and/or testing than healthy patients. (See 'Conditions that
increase perioperative risk' above.)

● Preoperative testing should be performed selectively, based on the patient's medical

status, the planned procedure, and the likelihood that test results will change
management or help with risk assessment. (See 'Preoperative testing' above.)

● For informed consent for anesthesia, patients should be made aware of the findings
from their preoperative evaluations and perioperative risks, to allow shared decisions
about options for care.

● For patients with do not resuscitate (DNR) orders, the patient's acceptance of specific
procedures and levels of resuscitation should be determined and documented, including
 the procedures necessary for anesthesia that would be considered resuscitation in
other circumstances. (See 'Consent and decision making' above.)

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Topic 94539 Version 20.0

GRAPHICS

Criteria and medical conditions for which preoperative evaluation is

recommended before the date of surgery

Medical condition Criteria

General Age

Normal activity inhibited >65 years, unless surgery is minor (eg,

cataract, cystoscopy) and under monitored
Monitoring or medical assistance at home
anesthesia care
within two months
Language
Hospital admission within two months
Patient or parent/guardian cannot hear,
Obesity (BMI >40 kg/m 2)
speak, or understand English
Frailty
Anesthesia related
Malnourishment
Patient has had previous difficult intubation,
Cardiovascular paralysis or nerve damage during anesthesia,
or patient or family has had previous
Coronary artery disease
elevated temperature during anesthesia, is
Arrhythmias allergic to succinylcholine, has malignant
Systolic blood pressure >160 mmHg or hyperthermia or pseudocholinesterase
diastolic blood pressure >100 mmHg deficiency

Heart failure Procedure related

Respiratory Intraoperative blood transfusion likely

Asthma, severe ICU admission likely

COPD with symptoms High-risk surgery

Exacerbation or progression of COPD or Pregnancy

asthma within two months Patient is pregnant (unless the procedure is
Previous airway surgery termination)

Unusual airway anatomy

Airway tumor or obstruction

Home ventilatory assistance or monitoring

OSA without PAP therapy

Endocrine

Diabetes requiring insulin therapy

Adrenal disorders

Active thyroid disease

Central nervous system/Neuromuscular

Seizure disorder

CNS disease (eg, multiple sclerosis)

Myopathy or other muscle disorders

 Hepatic

Active hepatobiliary disease or compromise

Renal

Renal insufficiency or failure

Musculoskeletal

Kyphosis or scoliosis compromising function

Temporomandibular joint disorder limiting

mouth opening

Cervical or thoracic spine injury/disease

Oncology

Chemo- or radiotherapy within last two

months

Significant physiologic compromise from

disease or treatment

This table shows medical conditions and other patient criteria for preanesthesia evaluation before the
day of surgery. For further information, refer to UpToDate content on preanesthesia evaluation for
noncardiac surgery.

BMI: body mass index; COPD: chronic obstructive pulmonary disease; OSA: obstructive sleep apnea; PAP:
positive airway pressure; CNS: central nervous system; ICU: intensive care unit.

Graphic 114155 Version 2.0

Triage guidelines

Patients for low risk procedures typically done with sedation

In-person evaluation well before the day of surgery is recommended for patients with any one of the
conditions from List 1

Triage guidelines for moderate-high risk procedures

In-person evaluation well before the day of surgery is recommended for patients with any one of the
conditions from List 1 or List 2

List 1:

1. Poor historians who do not know their medications or medical history

2. Unable to lie flat and still for the duration of the procedure

3. Obstructive sleep apnea without treatment

4. BMI >40

5. Heart failure

6. Pacemaker or implantable cardiac defibrillator

7. Hospitalization for medical problems within the last two months

8. Unable to perform activities of daily living (feeding or dressing oneself)

9. Myocardial infarction within the last 60 days

10. Coronary stents within the last six months

11. Stroke or TIA within the last three months

12. Use of anticoagulants if these must be stopped for the procedure

13. Oxygen use

14. Previous serious problems with anesthesia such as malignant hyperthermia, nerve damage

15. Dialysis patient

16. Severe liver disease

17. Cannot hear, speak, or understand English

18. Significant dementia or cognitive impairment

19. Pregnancy (unless procedure is a termination)

20. Obviously difficult airway or history of same

21. Poorly controlled hypertension (SBP >160; DBP >100)

22. Poorly controlled seizure disorder

23. Pulmonary hypertension

 24. Significant airway abnormalities (goiter, tumors, tracheostomy)

25. Hospitalization within the last two months unless the surgery was planned during the
hospitalization

List 2:

1. Age >65 years

2. Taking >8 prescription medications

3. Heart disease of any type

4. Medical condition inhibiting normal daily activity

5. Inability to climb one flight of stairs

6. Conditions necessitating assistance or monitoring at home within last three months

7. Diabetes mellitus

8. Chronic pain

9. Kidney disease

10. Liver disease

11. Significant lung disease (use of daily medications)

12. Likely to require a blood transfusion

13. Patient refusing blood transfusion

14. Planned postoperative ICU admission

15. Previous transplant

16. Significant spine disease (eg, scoliosis or neurologic symptoms)

17. Rheumatoid arthritis

18. Chemotherapy or radiation therapy within the previous three months

19. Active cancer

20. Thyroid disease

21. Adrenal disease

22. Neurologic disease (seizure, paralysis)

23. Chronic obstructive lung disease

24. Muscular dystrophies

This table shows suggested criteria for triaging patients for preanesthesia evaluation prior to or on the
day of surgery. For further information, refer to UpToDate content on preanesthesia evaluation for
noncardiac surgery.

BMI: body mass index; TIA: transient ischemic attack; SBP: systolic blood pressure; DBP: diastolic blood
pressure: ICU: intensive care unit.

Graphic 114156 Version 1.0

Patient preoperative history

Name: DOB: Preferred daytime phone #:

Planned surgery: Today's date:

Surgeon:

Primary care physician: PCP phone #:

Please list all previous surgeries (and approximate dates)

Please list any allergies to medications, latex, food, or other (and your reactions to them)

List all medications (include over-the-counter drugs, inhalers, herbals, supplements, and
aspirin)

Drug name Dose and how often? Drug name Dose and how often?

1. 7.

2. 8.

3. 9.

4. 10.

5. 11.

6. 12.

Weight: (lbs or kg) ____

Height: (inches or cm) ____
(Circle the measurement units you use)

Please check any of the following that apply to your health:

Heart attack at any time Congenital heart disease

Heart attack within past 60 days Hypertension

Chest pain or pressure with activity Murmur

Angina Valve disorder

Heart failure LVAD

Heart surgery Heart device

Heart stent in the last 6 months Pacemaker

Unable to climb 2 flights of stairs or Defibrillator

walking 2 blocks because of chest pain or
trouble breathing

Heart stent at any time Fainted in the last year

Atrial fibrillation Pain in legs while walking

 Arrhythmia None of these

Oxygen at home COPD

Pulmonary hypertension Pneumonia in last 2 months

Trouble breathing at rest or with minimal Any problems with your lungs
exertions

Asthma Severe cough

None of these

Face, arm, or leg weakness Myasthenia gravis

Stroke/TIA within past 60 days Muscular dystrophy

Stroke or TIA at any time Spinal cord injury

Paralysis Brain tumor

Difficulty speaking Brain aneurysm or AVM

Dementia Epilepsy, blackouts, or seizures

Parkinson disease None of these

Hospitalized in last 30 days Hypothyroidism

Anemia Adrenal disorder

Sickle cell disease Pituitary disorder

Blood transfusion in last 3 months Dialysis

Blood clots/pulmonary embolus Lupus

Diabetes Rheumatoid arthritis

Cancer: What type? ________ Scleroderma

Chemo or radiation last 3 months Sjogren's

Kidney disease other than stones Jehovah's Witness

Liver disease Use illegal drugs (excluding marijuana)

Cirrhosis Kidney failure

Hepatitis B/C Taking antibiotics for any reason

Jaundice HIV

Hyperthyroidism None of these

Blood thinners or anticoagulants other than Von Willebrands

aspirin

Bleeding with surgery or tooth extractions Known bleeding disorder

Hemophilia Severe nose bleeds

 None of these

Malignant hyperthermia (in blood relatives Dentures

or self) with anesthesia

Severe nausea or vomiting from anesthesia Problems opening your mouth

Difficult airway with anesthesia Loose teeth

None of these

Unintentional weight loss >10 lbs Difficulty doing your own shopping

Difficulty getting out of bed/chair by yourself Feel that everything you did was an effort: ____
days in the last week

Difficulty making your own meals Need assistance with eating or bathing or
dressing

Your physical abilities limit your daily activities Fallen in the last 6 months ( ____ times)

None of these

Very loud snoring High blood pressure/hypertension

Tired/fall asleep frequently during the day Sleep apnea; NO CPAP

Observed to stop breathing during sleep Sleep apnea; use CPAP

None of these

Cannot speak and/or understand English Deaf

Cannot lie flat for 45 minutes Blind

Currently pregnant. Last menstrual period began: ________

Smoker (current or past) ____ packs/day for ____ years. Quit date: ________

Drink alcohol. How much each day? ____ beers ____ glasses of wine ____ shots of hard alcohol

None of these

Please list any medical illness or medications not noted already:

The graphic shows an example of a form that would be used to start a medical history during
evaluation in anticipation of anesthesia. For further information, refer to UpToDate content on
preanesthesia evaluation for noncardiac surgery.

DOB: date of birth; PCP: primary care physician; COPD: chronic obstructive pulmonary disease; TIA: transient
ischemic attack; AVM: arteriovenous malformation; CPAP: continuous positive airway pressure.

Graphic 114154 Version 2.0

Patient history for airway assessment

1. Previous airway management documentation

Check anesthesia records for previous difficulties and ask patients whether they are aware of any
anesthetic problems

2. Conditions associated with airway difficulties

History of difficult airway

History of aspiration pneumonia after intubation

History of dental or oral trauma following intubation

Head and neck irradiation

Head and neck surgery

Cervical spine disease

Cervical spine surgery

Obstructive sleep apnea

Acromegaly

Rheumatoid arthritis

Ankylosing spondylitis

Marfan's syndrome

Pierre-Robin syndrome

Klippel-Feil abnormalities of the cervical spine

Significant sore throat after anesthesia

Previous airway injury during anesthesia

Patient reporting need for a "small tube"

Head, neck, and oropharyngeal

Tumors

Infections

Hematomas

Trauma

Cystic hygroma

Spinal muscular atrophy

Graphic 114346 Version 2.0

Duke activity status index questionnaire to determine functional capacity [1]

Activity Weight
Can you...

1. Take care of yourself, that is, eating, dressing, bathing or using the toilet? 2.75

2. Walk indoors, such as around your house? 1.75

3. Walk a block or 2 on level ground? 2.75

4. Climb a flight of stairs or walk up a hill? 5.50

5. Run a short distance? 8.00

6. Do light work around the house like dusting or washing dishes? 2.70

7. Do moderate work around the house like vacuuming, sweeping floors, or carrying in 3.50
groceries?

8. Do heavy work around the house like scrubbing floors, or lifting or moving heavy 8.00
furniture?

9. Do yardwork like raking leaves, weeding or pushing a power mower? 4.50

10. Have sexual relations? 5.25

11. Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, 6.00
or throwing a baseball or football?

12. Participate in strenuous sports like swimming, singles tennis, football, basketball or 7.50
skiing?

Total DASI score: ______

METs [(DASI score × 0.43) + 9.6] / 3.5: ______
​ The higher the DASI score, the more physically active the patient is. Patients who can achieve <4
METs have poor functional capacity, 4 to 10 METs suggest moderate functional capacity, and >10 METs
suggest excellent functional capacity.

DASI: Duke activity status index; METs: metabolic equivalents.

Reference: ​
1. ​Hlatky MA, Boineau RE, Higginbotham MB, et al. A brief self-administered questionnaire to determine
functional capacity (the Duke Activity Status Index). Am J Cardiol 1989; 64:651.
Reproduced with permission from: Duke University. Copyright © 1989 Duke University. All rights reserved.

Graphic 121071 Version 2.0

Efferent and afferent signals that contribute to the sensation of
dyspnea

The symptom of dyspnea likely arises from a range of sensory inputs, many of which
lead to qualitatively distinct descriptive phrases used by patients. The sensation of
respiratory effort arises from signals transmitted from the motor cortex to the
sensory cortex (green arrow) when outgoing motor commands are sent to the
ventilatory muscles (blue arrow). Motor output from the brain stem (blue arrow)
may also be accompanied by signals transmitted to the sensory cortex, contributing
to the sensation of effort (dotted green arrow).
The sensation of air hunger probably derives from a combination of stimuli that
increase the drive to breathe such as insufficient oxygen or excess carbon dioxide
(mediated by signals from chemoreceptors in the carotid body and aortic arch),
acute hypercapnia or acidemia (mediated by signals from the peripheral and central
chemoreceptors), airway and interstitial inflammation (mediated by pulmonary
afferents), and vascular receptors. The intensity of air hunger is increased when
there is a perceived mismatch between the outgoing efferent messages to the
ventilatory muscles and incoming afferent signals from the lungs and chest wall.
Chest tightness, commonly associated with bronchospasm, is mediated by
stimulation of vagal-irritant receptors. Afferent signals (red arrows) from airway,
lung, and chest wall receptors most likely pass through the brain stem before being
transmitted to sensory cortex, although it is also possible that some afferent
information bypasses the brain stem and goes directly to sensory cortex (dotted
arrow).

Red arrows: afferent signals; Blue arrows: efferent signals; Green arrows: signals within the
central nervous system; Dotted lines: hypothetical pathways; Circles: chemoreceptors;
Squares: mechanoreceptors.

Graphic 69322 Version 5.0

Conditions associated with chronic or recurrent dyspnea

Upper airway
Laryngeal mass

Vocal fold paralysis

Inducible laryngeal obstruction (also known as paradoxical vocal fold motion)

Goiter

Neck mass compressing airway

Chest/abdominal wall
Diaphragmatic paralysis

Kyphoscoliosis

Late pregnancy

Massive obesity

Ventral hernia

Ascites

Intra-abdominal process

Pulmonary
Asthma

Bronchiectasis

Bronchiolitis

COPD/emphysema

Interstitial lung disease

Mass compressing or occluding airway

Pleural effusion

Previous major lung resection (eg, lobectomy, pneumonectomy)

Pulmonary right-to-left shunt

Pulmonary hypertension

Trapped lung

Venous thromboembolism (VTE)

Cardiac
Arrhythmia

Constrictive pericarditis, pericardial effusion

Coronary heart disease

Deconditioning

Heart failure (systolic or diastolic dysfunction)

 Intracardiac shunt

Restrictive cardiomyopathy

Valvular dysfunction

Neuromuscular disease
Amyotrophic lateral sclerosis

Phrenic nerve disease/dysfunction

Glycolytic enzyme defects (eg, McArdle)

Mitochondrial diseases

Polymyositis/dermatomyositis

Toxic/metabolic/systemic
Anemia

Metabolic acidosis

Renal failure

Thyroid disease

Miscellaneous
Anxiety

Early pregnancy (effect of progesterone)

COPD: chronic obstructive pulmonary disease.

Graphic 104817 Version 4.0

Causes of acute dyspnea

Cardiovascular system
Acute myocardial ischemia

Heart failure

Cardiac tamponade

Respiratory system
Bronchospasm

Pulmonary embolism

Pneumothorax

Pulmonary infection - bronchitis, pneumonia

Upper airway obstruction - aspiration, anaphylaxis

Graphic 82700 Version 1.0

American Society of Anesthesiologists (ASA) Physical Status Classification
System

ASA PS Examples, including, but not

Definition
classification limited to:

ASA I A normal healthy patient. Healthy, non-smoking, no or minimal

alcohol use.

ASA II A patient with mild systemic disease. Mild diseases only without substantive
functional limitations. Current smoker,
social alcohol drinker, pregnancy, obesity
(30<BMI<40), well-controlled DM/HTN,
mild lung disease.

ASA III A patient with severe systemic disease. Substantive functional limitations; one or
more moderate to severe diseases.
Poorly controlled DM or HTN, COPD,
morbid obesity (BMI ≥40), active
hepatitis, alcohol dependence or abuse,
implanted pacemaker, moderate
reduction of ejection fraction, ESRD
undergoing regularly scheduled dialysis,
premature infant PCA<60 weeks, history
(>3 months) of MI, CVA, TIA, or
CAD/stents.

ASA IV A patient with severe systemic disease Recent (<3 months) MI, CVA, TIA, or
that is a constant threat to life. CAD/stents, ongoing cardiac ischemia or
severe valve dysfunction, severe
reduction of ejection fraction, sepsis,
DIC, ARDS, or ESRD not undergoing
regularly scheduled dialysis.

ASA V A moribund patient who is not expected Ruptured abdominal/thoracic aneurysm,

to survive without the operation. massive trauma, intracranial bleed with
mass effect, ischemic bowel in the face
of significant cardiac pathology or
multiple organ/system dysfunction.

ASA VI A declared brain-dead patient whose

organs are being removed for donor
purposes.

The addition of "E" to the numerical status (eg, IE, IIE, etc.) denotes Emergency surgery (an
emergency is defined as existing when delay in treatment of the patient would lead to a significant
increase in the threat to life or body part).

BMI: body mass index; DM: diabetes mellitus; HTN: hypertension; COPD: chronic obstructive pulmonary
disease; ESRD: end-stage renal disease; PCA: post conceptual age; MI: myocardial infarction; CVA:
cerebrovascular accident; TIA: transient ischemic attack; CAD: coronary artery disease; DIC: disseminated
intravascular coagulation; ARDS: acute respiratory distress syndrome.

ASA Physical Status Classification System (Copyright © 2014) is reprinted with permission of the American
Society of Anesthesiologists, 1061 American Lane, Schaumburg, Illinois 60173-4973.
Graphic 87504 Version 8.0
Mortality versus ASA classification and procedure risk

The observed mortality rate as a function of American Society of Anesthesiologists' physical status and
surgery-specific risk.

ASA: American Society of Anesthesiologists.

From: Glance L, Lustik SJ, Hannan EL, et al. The surgical mortality probability model derivation and validation of a
simple risk prediction rule for noncardiac surgery. Ann Surg 2012; 255:696. DOI: 10.1097/SLA.0b013e31824b45af.
Copyright © 2012. Reproduced with permission from Lippincott Williams & Wilkins. Unauthorized reproduction of this
material is prohibited.

Graphic 113974 Version 1.0

Risk factors for revised cardiac risk index

High risk surgery (intraperitoneal, intrathoracic, or suprainguinal vascular procedures)

Ischemic heart disease (by any diagnostic criteria)

Heart failure

Cerebrovascular disease

Diabetes mellitus requiring insulin

Creatinine ≥2.0 mg/dL

Adapted from: Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple
index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999; 100:1043.

Graphic 114577 Version 1.0

Selected examples of low, intermediate, and high intrinsic cardiac risk
operations

Estimated
cardiac risk of
Description Odds ratio* (95% CI)
hypothetical
patient ¶ (%)

Low intrinsic cardiac risk

Partial mastectomy (lumpectomy) 0.22 (0.15-0.31) 0.05

Arthroscopic rotator cuff repair 0.32 (0.19-0.54) 0.07

Simple mastectomy (complete breast) 0.37 (0.26-0.50) 0.08

Laparoscopic appendectomy 0.45 (0.33-0.62) 0.10

Laparoscopic cholecystectomy 0.62 (0.53-0.72) 0.14

Intermediate intrinsic cardiac risk

Transurethral resection of bladder tumor, large 0.85 (0.61-1.20) 0.19

Laparoscopic prostatectomy 0.88 (0.69-1.12) 0.19

Open appendectomy 0.95 (0.51-1.75) 0.21

Total hip arthroplasty 0.95 (0.83-1.08) 0.21

Laparoscopic radial hysterectomy with bilateral 1.05 (0.57-1.94) 0.23

salpingo-oophorectomy

High intrinsic cardiac risk

Laparoscopic total abdominal colectomy with 1.50 (0.92-2.44) 0.33

ileostomy

Breast reconstruction with free flap 1.52 (0.81-2.86) 0.33

Open cholecystectomy 1.55 (1.25-1.92) 0.34

Open ventral hernia repair, incarcerated or 1.78 (1.29-2.44) 0.39

strangulated, recurrent

Whipple procedure, pylorus-sparing 4.70 (4.00-5.53) 1.02

ASA: American Society of Anesthesiologists.

* Odds ratios are relative to the statistically estimated average procedure. Values greater than 1.0 represent
higher than average risk for perioperative adverse cardiac events, whereas values less than 1.0 represent lower
than average risk for perioperative adverse cardiac events.
¶ The hypothetical patient used to estimate numerical risk values across all operations for comparison was a 67-
year-old white female with hypertension, diabetes requiring oral therapy, and a body mass index of 32 (class I
obesity), who is functionally independent, does not smoke, and is of ASA physical class II.

From: Liu JB, Liu Y, Cohen ME, et al. Defining the intrinsic cardiac risks of operations to improve preoperative
cardiac risk assessments. Anesthesiology 2018; 128:283. DOI: 10.1097/ALN.0000000000002024. Copyright ©
2018 American Society of Anesthesiologists. Reproduced with permission from Wolters Kluwer Health.
Unauthorized reproduction of this material is prohibited.

Graphic 116645 Version 1.0

ACS NSQIP surgical risk calculator report
This graphic shows an example of the type of report that would be generated after entering patient data into the
ACS NSQIP calculator, based on a fictitious patient. The actual report would reflect the individual patient data.

ACS: American College of Surgeons; NSQIP: National Surgical Quality Improvement Program.

Reproduced with permission from the American College of Surgeons National Surgical Quality Improvement Program.
Copyright © 2007 - 2016. All rights reserved.

Graphic 113975 Version 2.0

Surgical mortality probability model for predicting risk of 30-day mortality
after noncardiac surgery

Risk factor Points assigned

ASA physical status

I 0

II 2

III 4

IV 5

V 6

Procedure risk

Low risk 0

Intermediate risk 1

High risk 2

Emergency

Nonemergent 0

Emergency surgery 1

Class Point total Mortality

I 0 to 4 <0.50%

II 5 to 6 1.5 to 4.0%

III 7 to 9 >10%

From: Glance L, Lustik SJ, Hannan EL, et al. The surgical mortality probability model derivation and validation of
a simple risk prediction rule for noncardiac surgery. Ann Surg 2012; 255:696. DOI:
10.1097/SLA.0b013e31824b45af. Copyright © 2012. Reproduced with permission from Lippincott Williams &
Wilkins. Unauthorized reproduction of this material is prohibited.

Graphic 113976 Version 1.0

Checklist for the optimal preoperative assessment of the geriatric surgical
patient

In addition to conducting a complete history and physical examination of the patient, the
following assessments are strongly recommended:

Assess the patient's cognitive ability and capacity to understand the anticipated surgery.

Screen the patient for depression.

Identify the patient's risk factors for developing postoperative delirium.

Screen for alcohol and other substance abuse/dependence.

Perform a preoperative cardiac evaluation according to the American College of

Cardiology/American Heart Association algorithm for patients undergoing noncardiac surgery.

Identify the patient's risk factors for postoperative pulmonary complications and implement
appropriate strategies for prevention.

Document functional status and history of falls.

Determine baseline frailty score.

Assess patient's nutritional status and consider preoperative interventions if the patient is at
severe nutritional risk.

Take an accurate and detailed medication history and consider appropriate perioperative
adjustments. Monitor for polypharmacy.

Determine the patient's treatment goals and expectations in the context of the possible
treatment outcomes.

Determine patient's family and social support system.

Order appropriate preoperative diagnostic tests focused on elderly patients.

Determine venue for surgery.

Original figure modified for this publication. From: Chow WB, Rosenthal RA, Merkow RP, et al. Optimal
preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College
of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll
Surg 2012; 215:453. Table used with the permission of Elsevier, Inc. All rights reserved.

Graphic 114173 Version 2.0

Preoperative frailty assessment

Frailty
Assessment Score Points
criteria

Shrinkage Ask the patient: Have you If Yes, add 1 point

unintentionally lost ≥10 lbs in the
past year? Yes / No

Weakness 1. Ask the patient to hold Compare patient's average with the
(grip dynamometer in dominant hand lowest 20th percentile by gender and
strength) with arms parallel to their body BMI shown below:
without squeezing arms against Men Women
their body.
2. Adjust the handle to ensure that BMI Kg BMI Kg
the middle phalanx rests on the force force
inner handle. ≤24 ≤29 ≤23 ≤17
3. Ask the patient to squeeze the
24.1 to ≤30 23.1 to ≤17.3
handle and record.
26 26
4. Perform three trials, and obtain
the average value. Record 26.1 to ≤31 26.1 to ≤18
results below: 28 29

>28 ≤32 >29 ≤21

Trial 1: ________ kg force
Add 1 point if the average falls within or
Trial 2: ________ kg force below the above values
Trial 3: ________ kg force
Average: ________ kg force

Exhaustion Ask the patient the following two

questions:
0 1 2 3
1. How often in the last week did
Rarely Some Moderate Most of
you feel that everything you
or none or a amount the time
did was an effort? ________
of the little of of the (>4
2. How often in the last week did time the time time days)
you feel that you could not (<1 (1 to 2 (3 to 4
get going? ________ day) days) days)

Add 1 point for a score of 2 or 3 for

EITHER question

Low physical Ask the patient the following four Add 1 point for any No answer
activity questions:

1. Can you get out of bed or

chair yourself? Yes / No
2. Can you dress and bathe
yourself? Yes / No
3. Can you make your own
meals? Yes / No
4. Can you do your own
shopping? Yes / No
 Slowness 1. Ask the patient to stand up and
walk toward the tape on the Men Women
ground.
2. Using a stopwatch, record the
Height Time Height Time
time it takes for the patient to
walk 15 feet. Record results ≤173 ≥7 ≤159 cm ≥7
below: cm seconds seconds

>173 ≥6 >159 cm ≥6
Trial: ________ seconds
cm seconds seconds

Add 1 point if the trial time falls higher

than the above values

Frailty score:

Total the number of points for each criterion (the total should be 0 to 5) to determine the frailty
score.​
0 to 1: Not frail
2 to 3: Intermediate (pre-frail)
4 to 5: Frail
If the patient is in the intermediate frail or frail categories, please notify the surgeon.

BMI: body mass index.

Adapted from:​
1. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol
Sci Med Sci 2001; 56:M146.
2. Frailty. In: Geriatrics Evaluation & Management Tools: Clinical Templates to Support Clinicians and
Systems that are Caring for Older Adults, American Geriatrics Society, New York 2013.

Graphic 114174 Version 1.0

Algorithm for patients with a heart failure syndrome with an
indication for urgent noncardiac surgery

ACS: acute coronary syndrome; HF: heart failure; MACE: major adverse cardiac events.
* Refer to UpToDate content on management of ACS.
¶ Stable HF syndromes include stable HF as well as asymptomatic left ventricular dysfunction.
Δ Refer to UpToDate content on management of heart failure with reduced ejection fraction,
heart failure with preserved ejection fraction, and refractory heart failure.

Graphic 105827 Version 2.0

Algorithm for patients with a heart failure syndrome with an
indication for elective noncardiac surgery

ACS: acute coronary syndrome; HF: heart failure; MACE: major adverse cardiac events.
* Refer to UpToDate content on management of ACS.
¶ Stable HF syndromes include stable HF as well as asymptomatic left ventricular dysfunction.
Δ Refer to UpToDate content on management of refractory heart failure.
Graphic 105828 Version 1.0
Frequency of echocardiograms in asymptomatic patients with VHD and normal
left ventricular function

Valve lesion
Stage Aortic Mitral
Aortic stenosis* Mitral stenosis
regurgitation regurgitation

Progressive Every 3 to 5 years Every 3 to 5 years Every 3 to 5 years Every 3 to 5 years

(stage B) (mild severity V max (mild severity) (MVA >1.5 cm 2) (mild severity)
2.0 to 2.9 m/second)

Every 1 to 2 years Every 1 to 2 years Every 1 to 2 years

(moderate severity (moderate severity) (moderate severity)
V max 3.0 to 3.9
m/second)

Severe Every 6 to 12 Every 6 to 12 Every 1 to 2 years Every 6 to 12

(stage C) months (V max ≥4 months (MVA 1.0 to 1.5 months
m/second) cm 2)

Dilating LV: more Once every year Dilating LV: more

frequently (MVA <1.0 cm 2) frequently

Patients with mixed valve disease may require serial evaluations at intervals earlier than recommended
for single valve lesions.

VHD: valvular heart disease; LV: left ventricle; MVA: mitral valve area; V max : maximum velocity.
* With normal stroke volume.

Reproduced from: Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of
patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57. Table used with the permission of Elsevier
Inc. All rights reserved.

Graphic 114573 Version 1.0

Summary of recommendations for AS: Timing of intervention

Class of Level of
Recommendations
recommendation evidence

AVR is recommended for symptomatic patients with severe I B

high-gradient AS who have symptoms by history or on
exercise testing (stage D1)

AVR is recommended for asymptomatic patients with severe I B

AS (stage C2) and LVEF <50%

AVR is indicated for patients with severe AS (stage C or D) I B

when undergoing other cardiac surgery

AVR is reasonable for asymptomatic patients with very IIa B

severe AS (stage C1, aortic velocity ≥5.0 m/s) and low
surgical risk

AVR is reasonable in asymptomatic patients (stage C1) with IIa B

severe AS and decreased exercise tolerance or an exercise
fall in BP

AVR is reasonable in symptomatic patients with low- IIa B

flow/low-gradient severe AS with reduced LVEF (stage D2)
with a low-dose dobutamine stress study that shows an
aortic velocity ≥4.0 m/s (or mean pressure gradient ≥40
mmHg) with a valve area ≤1.0 cm 2 at any dobutamine
dose

AVR is reasonable in symptomatic patients who have low- IIa C

flow/low-gradient severe AS (stage D3) who are
normotensive and have an LVEF ≥50% if clinical,
hemodynamic, and anatomic data support valve obstruction
as the most likely cause of symptoms

AVR is reasonable for patients with moderate AS (stage B) IIa C

(aortic velocity 3.0 to 3.9 m/s) who are undergoing other
cardiac surgery

AVR may be considered for asymptomatic patients with IIb C

severe AS (stage C1) and rapid disease progression and low
surgical risk

For the strength of recommendations: Class I means the procedure/treatment should be

performed/administered. Class IIa means it is reasonable to perform the procedure/administer
treatment. Class IIb means the procedure/treatment may be considered. Class III means that the
procedure or treatment is not useful/effective and may be harmful.
For the level of evidence: Level A means multiple populations evaluated; data derived from multiple
randomized clinical trials or meta-analyses. Level B means limited populations evaluated; data derived
from a single randomized trial or nonrandomized studies. Level C means very limited populations
evaluated; only consensus opinion of experts, case studies, or standard of care.

AS: aortic stenosis; AVR: aortic valve replacement by either surgical or transcatheter approach; BP: blood
pressure; LVEF: left ventricular ejection fraction.
Reproduced from: Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of
Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57. Table used with the permission
of Elsevier Inc. All rights reserved.

Graphic 98005 Version 2.0

Summary of recommendations for mitral stenosis intervention

Class of Level of
Recommendations
recommendation evidence

PMBC is recommended for symptomatic patients with I A

severe MS (MVA ≤1.5 cm 2, stage D) and favorable valve
morphology in the absence of contraindications

Mitral valve surgery is indicated in severely symptomatic I B

patients (NYHA class III/IV) with severe MS (MVA ≤1.5
cm 2, stage D) who are not high risk for surgery and who
are not candidates for or failed previous PMBC

Concomitant mitral valve surgery is indicated for patients I C

with severe MS (MVA ≤1.5 cm 2, stage C or D) undergoing
other cardiac surgery

PMBC is reasonable for asymptomatic patients with very IIa C

severe MS (MVA ≤1.0 cm 2, stage C) and favorable valve
morphology in the absence of contraindications

Mitral valve surgery is reasonable for severely symptomatic IIa C

patients (NYHA class III/IV) with severe MS (MVA ≤1.5
cm 2, stage D), provided there are other operative
indications

PMBC may be considered for asymptomatic patients with IIb C

severe MS (MVA ≤1.5 cm 2, stage C) and favorable valve
morphology who have new onset of AF in the absence of
contraindications

PMBC may be considered for symptomatic patients with IIb C

MVA >1.5 cm 2 if there is evidence of hemodynamically
significant MS during exercise

PMBC may be considered for severely symptomatic patients IIb C

(NYHA class III/IV) with severe MS (MVA ≤1.5 cm 2, stage
D) who have suboptimal valve anatomy and are not
candidates for surgery or at high risk for surgery

Concomitant mitral valve surgery may be considered for IIb C

patients with moderate MS (MVA 1.6 to 2.0 cm 2)
undergoing other cardiac surgery

Mitral valve surgery and excision of the left atrial IIb C

appendage may be considered for patients with severe MS
(MVA ≤1.5 cm 2, stages C and D) who have had recurrent
embolic events while receiving adequate anticoagulation

For the strength of recommendations: Class I means the procedure/treatment should be

performed/administered. Class IIa means it is reasonable to perform the procedure/administer
treatment. Class IIb means the procedure/treatment may be considered. Class III means that the
procedure or treatment is not useful/effective and may be harmful.
For the level of evidence: Level A means multiple populations evaluated; data derived from multiple
randomized clinical trials or meta-analyses. Level B means limited populations evaluated; data derived
from a single randomized trial or nonrandomized studies. Level C means very limited populations
evaluated; only consensus opinion of experts, case studies, or standard of care.

AF: atrial fibrillation; MS: mitral stenosis; MVA: mitral valve area; NYHA: New York Heart Association; PMBC:
percutaneous mitral balloon commissurotomy.

Reproduced from: Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of
Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57. Table used with the permission
of Elsevier Inc. All rights reserved.

Graphic 98396 Version 2.0

Preoperative cardiac risk assessment for determining the need for stress testing for pati
with CAD or with risk factors for CAD anticipating noncardiac surgery

This algorithm is to be used for patients ≥55 years of age or with risk factors for CAD (ie, family history of CAD, his
tobacco use, hyperlipidemia, diabetes mellitus, male sex, chronic kidney disease, other vascular disease).
Use this algorithm in conjunction with UpToDate content on estimation of cardiac risk prior to noncardiac surgery;
perioperative management of patients with valvular heart disease, heart failure, and arrhythmias; and interpretatio
stress testing.

CAD: coronary artery disease; MACE: major adverse cardiac events; RCRI: revised cardiac risk index; MET: metabolic equival
* Acute coronary syndrome includes acute myocardial infarction or unstable angina.
¶ The Gupta Perioperative Cardiac Risk Calculator.
Δ Functional capacity is usually described in terms of METs. Perioperative cardiac risk is elevated in patients incapable of 4 ME
daily activity. Examples of 4 METS of activity include walking up >1 flight of stairs at a normal pace without stopping, walking
ground at 4 miles per hour.
◊ Test results may affect the patient's decision to undergo the planned surgery, but may not affect care if the patient is unwill
undergo treatment for abnormalities (eg, coronary revascularization). Test results may also affect decisions about the extent
appropriateness of planned surgery, alternative treatment, perioperative monitoring, and perioperative medical management.
§ Other cardiac tests may be indicated (eg, echocardiogram, holter monitor) based on suspected or known cardiac disease ot
CAD.
¥ Not all abnormal stress test findings warrant further evaluation and treatment, or management that would delay surgery.

Graphic 121289 Version 1.0

Algorithm for the management of preoperative anemia

This algorithm is intended to help clinicians determine whether surgery should be

delayed for preoperative anemia. Testing for preoperative anemia is a key means of
avoiding unnecessary transfusions. In many cases, a cause such as iron deficiency
can be identified and treated. Clinical judgment is required to assess the urgency of
surgery and the benefits of delaying surgery. For example, it may not be necessary to
postpone minor procedures, such as cataract surgery. Anemia should always be
evaluated for the underlying cause so that appropriate treatment can be determined.
Refer to UpToDate for the approach to the anemia evaluation and for treatment of
specific causes of anemia.

MDS: myelodysplastic syndrome; AIHA: autoimmune hemolytic anemia.

* Refer to UpToDate for details of the indications for preoperative screening for anemia.
¶ Refer to UpToDate for indications for transfusion. Transfusion is reserved for the treatment
of severe or symptomatic anemia or if there is ongoing significant blood loss that would cause
severe or symptomatic anemia. Tolerance of anemia depends on the patient population.
Transfusion is a short-term therapy that does not address or treat the underlying cause of
anemia.
Δ Refer to UpToDate for the evidence for efficacy and safety of erythropoietin in various
patient populations.

Graphic 120496 Version 2.0

Rationale for preoperative testing

Preoperative testing is recommended when an abnormal result is suspected based on clinical

risk factors and the result will:

Establish a new diagnosis

Direct further beneficial preoperative testing or consultation

Impact decision to postpone or cancel surgery

Inform preoperative medication use

Influence type of surgery

Influence choice of anesthetic technique

Alter intraoperative monitoring or management

Change postoperative disposition

Establish perioperative risk profile for physicians and patient decisions

Graphic 114164 Version 1.0

Diagnostic testing for patients anticipating anesthesia and procedures

Age >65 Albumin, creatinine, hemoglobin

Alcohol abuse: ECG, electrolytes, hemoglobin, LFTs, platelet count, PT/INR

Anasarca: Albumin, BUN, creatinine, ECG, electrolytes, TSH, T3, T4

Anemia: CBC, creatinine, ferritin, iron, transferrin saturation, TSH, T3,

T4, Vit B 12

Bleeding disorder (personal or LFTs, platelet count, PT/INR, PTT

family history):

Blood loss (anticipated) significant: Hemoglobin, type and screen

BMI <16: Albumin, ECG, electrolytes, hemoglobin, PT/INR, TSH, T3, T4

BMI >50: ECG, HgA1c/glucose

Cardiac disease:

Arrhythmias (new or undiagnosed BNP, ECG, electrolytes, hemoglobin, TSH, T3, T4

brady, irregular, or tachy):

Chest pain (new or worsening): BNP, ECG, hemoglobin

Heart failure (decompensated or BNP, chest radiograph, creatinine, ECG, electrolytes,

NYHA class 3 or 4): hemoglobin

Murmur (undiagnosed): BNP, ECG

Chemotherapy (within last 30 days): BUN, CBC, creatinine, platelet count

CIED (pacemaker, ICD): ECG

Cocaine abuse: ECG

Contrast dye (anticipated use): Creatinine

Diabetes: Creatinine, HgA1c/glucose

Dyspnea (severe and undiagnosed): Albumin, BNP, BUN, chest radiograph, creatinine, ECG,
electrolytes, hemoglobin, TSH, T3, T4

Goiter: T3, T4, TSH

Hematologic disorders (eg, CBC, platelet count

leukemia, myeloma):

Hepatic disease: Albumin, BUN, creatinine, electrolytes, hemoglobin, LFTs,

platelet count, PT/INR

Hypercoagulable condition Platelet count, PTT

(undiagnosed):

Inflammatory bowel disease: Electrolytes, hemoglobin

Instrumentation of the urinary tract: Urinalysis

Malabsorption: Albumin, BUN, CBC, electrolytes, hemoglobin, PT/INR

Malnutrition: Albumin, BUN, CBC, creatinine, electrolytes, hemoglobin,

PT/INR

Medications:
 Amiodarone use: ECG, T3, T4, TSH

Digoxin: ECG, electrolytes

Diuretics: Electrolytes

Heparin (unfractionated): PTT

Steroids (systemic): Electrolytes, HgA1c/glucose

Thyroid replacement: TSH, T3, T4

Warfarin: PT/INR

Planned initiation of warfarin for first PT/INR

time in hospital:

Palpitations: ECG, hemoglobin, T3, T4, TSH

Positive antibody screen on previous Type and screen (except for procedures with no blood loss
type and screen: potential)

Pulmonary disease (eg, cough, Chest radiograph

severe dyspnea, abnormal findings
on chest examination):

Pulmonary HTN: ECG

Radiation therapy (to chest, breasts, Chest radiograph, ECG

lungs, thorax):

Renal disease: BUN, creatinine, electrolytes, hemoglobin

Suspected pregnancy: B-hCG

Syncope: BNP, creatinine, ECG, electrolytes, hemoglobin,

HgA1c/glucose, TSH, T3, T4

Thyroid disease: TSH, T3, T4

Tobacco use + diabetes + age >55 Creatinine

years:

Thrombocytopenia: Platelet count

Urinary tract infection (suspected): Urinalysis; sample hold for C/S if UA suggestive of infection

These tests should be done when one either suspects an undiagnosed or worsening condition or when
no laboratory values are available and the results will affect perioperative management. Typically these
would apply only for intermediate-high risk surgeries. Previously abnormal results predict new or
worsening results or may now be normal.

ECG: electrocardiogram; LFTs: liver function tests; PT/INR: prothrombin time/international normalized ratio;
TSH: thyroid stimulating hormone; CBC: complete blood count; PTT: partial thromboplastin time; T3:
liothyronine sodium; T4: thyroxine; HbA1c: glycated hemoglobin; BNP: brain natriuretic peptide; BUN: blood
urea nitrogen; CIED: cardiovascular implantable electronic device; ICD: implantable cardioverter-defibrillator;
b-hCG: beta human chorionic gonadotropin; C/S: culture and sensitivity; UA: urine analysis.

Graphic 114157 Version 3.0

Recommendations for patient-specific baseline testing before anesthesia*

Procedure/patient type Test

Injection of contrast dye Creatinine ¶

Potential for significant blood loss Hemoglobin/hematocrit ¶

Likelihood of transfusion requirement Type and screen

Possibility of pregnancy Pregnancy test Δ

End-stage renal disease Potassium level ◊

Diabetes Glucose level determination on day of surgery ◊

For further information, refer to UpToDate content on preanesthesia evaluation for noncardiac surgery.

* For testing recommendations for disease evaluation refer to UpToDate graphic on diagnostic testing for
patients anticipating anesthesia.
¶ Results from laboratory tests within three months of surgery are acceptable unless major abnormalities are
present or the patient's condition has changed.
Δ Pregnancy testing is not recommended before the day of surgery unless pregnancy is suspected.
◊ No absolute level of either potassium or glucose has been determined to preclude surgery and anesthesia. The
benefits of the procedure must be balanced against the risk of proceeding in a patient with abnormal results.

Graphic 114163 Version 2.0

Checklist used to assess the possibility of pregnancy

The provider can be reasonably certain that the woman is not pregnant if she has no symptoms
or signs of pregnancy and meets ANY of the following criteria:

She has not had intercourse since her last normal menses.

She has been correctly and consistently using a reliable method of contraception.

She is within the first 7 days after normal menses.

She is within 4 weeks postpartum (for nonlactating women).

She is within the first 7 days postabortion or miscarriage.

She is fully or nearly fully breastfeeding, amenorrheic, and less than 6 months postpartum.

A systematic review of studies evaluating the performance of a pregnancy checklist compared with
urine pregnancy test to rule out pregnancy concluded the negative predictive value of a checklist
similar to the one above was 99 to 100%.

Data from:​
1. Tepper NK, Marchbanks PA, Curtis KM. Use of a checklist to rule out pregnancy: A systematic review.
Contraception 2013; 87:661.
2. Curtis KM, Tepper NK, Jatlaoui TC, et al. United States Medical Eligibility Criteria for Contraceptive Use,
2016. MMWR Recomm Rep 2016; 65:1.

Graphic 67567 Version 18.0

Shared decision making

Patient is informed of all medical issues

Patient is informed of recommendations and all options for care

Patient is aware of the benefits and risks of the options of care

Patient's personal expectations and concerns are considered

Providers consider the patient's viewpoint

Providers answer all the patient's questions

Patient actively participates in all decisions

Adapted from: Flierler WJ, Nübling M, Kasper J, Heidegger T. Implementation of shared decision making in
anaesthesia and its influence on patient satisfaction. Anaesthesia 2013; 68:713.

Graphic 114031 Version 2.0

Contributor Disclosures
BobbieJean Sweitzer, MD, FACP Nothing to disclose Natalie F Holt, MD, MPH Nothing to
disclose Marianna Crowley, MD Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for references
to be provided to support the content. Appropriately referenced content is required of all authors and
must conform to UpToDate standards of evidence.

Conflict of interest policy