I. History and physical examination—special emphasis on identification of undiagnosed cardiopulmonary disease
A. Past medical history
B. Past surgical history
C. Family history
D. Psychosocial history
E. Allergies
F. Review of systems
G. Current medications, including over-the-counter and herbal supplements
H. Head-to-toe physical examination
II. Laboratory and diagnostic screening
A. Urinalysis
B. Complete blood count
C. Posteroanterior and lateral chest radiographs
D. Patients >40 years of age
1. Electrocardiogram
2. Stool for occult blood
3. Blood chemistry screening battery
E. Pulmonary function testing
1. Not routinely obtained
2. Should be ordered for
a. Patients having lung surgery
b. Patients with a history of smoking of >10 pack-years who are having coronary artery bypass grafting (CABG) or upper or lower abdominal surgery
III. Assessment of surgical risk
A. Nutritional status
1. Dietary history
2. Serum albumin <3 g/dl correlates with prolonged recovery and increased mortality
3. Serum transferrin <150 mg/dl correlates with prolonged recovery and increased mortality
4. Weight loss >20% caused by illness correlates with prolonged recovery and increased mortality
B. Immune competence
1. Total lymphocyte count
2. Cell-mediated immunity measured by serology
3. Known immunodeficiency, such as HIV
4. Others factors that increase risk of infection
a. Corticosteroid use
b. Immunosuppressive agents
c. Cytotoxic drugs
d. Prolonged antibiotic therapy
e. Renal failure
f. Irradiation
g. Hyperglycemia
C. Bleeding risk factors
1. Patient history
a. Prolonged bleeding after procedure or injury
b. Bleeding 1 day after tooth extraction
c. Spontaneous bruising
d. Liver or kidney disease
e. Recent thromobolytics, anticoagulants, NSAIDs, or other drugs that prolong bleeding
f. Personal (moral, ethical, religious) contraindication to transfusion
2. Physical examination—Consider presence of
a. Hepatosplenomegaly
b. Petechiae
c. Ecchymoses
d. Findings consistent with anemia
3. Diagnostic findings
a. Anemia
b. Prolonged prothrombin time or partial thromboplastin time (PT/PTT)
c. Thrombocytopenia
d. Elevated liver function tests (LFTs)
E. Patients with coronary artery disease
1. Reduce systolic BP to <140 mmHg and diastolic BP to <90 mmHg
2. In low-risk patients,
a. Exercise tolerance test should be conducted when history is unreliable
b. Dipyridamole thallium scintigraphy, stress echocardiography, or ambulatory ischemia monitoring should be performed in patients unable to exercise
3. High-risk patients: Postpone surgery unless emergency
4. Patient should be at least 3 months, and preferably 6 months, post myocardial infarction
F. Patients with congestive heart failure (CHF)
1. Should receive medications up to and including day of surgery
2. Document objective assessment of left ventricular (LV) function (echocardiography)
G. Assessment of pulmonary risk
1. Chronic lung disease (obstructive or restrictive)
2. Morbid obesity
3. Tobacco use
IV. Control of chronic illness
A. Diabetes mellitus (DM)
1. Patients who require insulin
a. Type 1 DM
b. Type 2 DM managed with insulin
c. Type 2 DM managed with oral agents who are having major procedures
d. Methods of insulin administration
i. One-half to two-thirds usual dose subcutaneously
ii. 5-15 units regular insulin in 5% to 10% glucose at the rate of 100 ml/hour (maintain serum glucose <200 mg/dl)
iii. Infuse insulin via IV drip at 0.5-1.5 units/hour; infuse glucose separately to maintain serum glucose <200 mg/dl
iv. Portland Protocol
v. Monitor serum glucose every 2 to 4 hours
2. Patients not requiring insulin
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a. Diet-controlled diabetics
i. Avoid glucose solutions on the day of surgery
b. Type 2 DM controlled with oral agents
i. Discontinue oral agents on the day before surgery
ii. Infuse 5% glucose at 100 ml/hour
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