MD & DO How do you perform a preoperative clearance evaluation?

[cbrons]

Did you ever ask yourself:

• How do you perform an adequate preoperative H&P
• What needs to be included to my presentation when I am assigned a patient to "clear" for surgery?Which tests are important to order during the preop evaluation and in what patients?
• Which drugs need to be stopped in the perioperative period and when?
  • How high of a dose of glucocorticoids and how long must you be on it before you need increased dose in perioperative period?
  • What do you do with insulin in the perioperative period?
  • When do you stop someone's Lovenox or Warfarin and what tests need to be performed when?
  • What about all these other rando drugs they are on? Do they need to be stopped and when?
• What is a "normal" postoperative fever and is Uworld/First Aid correct when it says that atelectasis is a major cause?
• What are the general rules for perioperative insulin management?
• What are some general checklists to mitigate postoperative pulmonary risk?

If yes, then see the .pdf attached to this thread. It's something I worked on over the course of several weeks while completing my 5th and final medicine sub-internship during the final month of medical school.

Of course, I would love if anyone has any clarifications or corrections to submit. That is part of the reason I'm posting this here.

LAST UPDATE: 6/29/2017

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[Lexicon0]

Incoming surgical sub resident. This is solid - thanks for sharing!

 

[sinombre]

Can't open it on my phone for some reason but thanks for posting. Getting ready to start a surgery internship so I'm sure something like this will help.

 

[Lawpy]

Great stuff thanks! Would be interested to know @SouthernSurgeon @ProfMD @ThoracicGuy thoughts on the guide.

 

[cbrons]

Great stuff thanks! Would be interested to know @SouthernSurgeon @ProfMD @ThoracicGuy thoughts on the guide.

Would love for anyone to provide feedback on it. I'm sure I am missing something important.

The surgical risk categories was taken from a lecture given by a local residency program. I haven't found an official list of risk categories based on type of surgery.

 

[xClashx]

thank you so much! my first rotation is in surgery (got the short straw). Any other recommendations on resources? Our surg rotation is only 1 month =/

 

[Ismet]

Did you ever ask yourself:

• How do you perform an adequate preoperative H&P
• What needs to be included to my presentation when I am assigned a patient to "clear" for surgery?Which tests are important to order during the preop evaluation and in what patients?
• Which drugs need to be stopped in the perioperative period and when?
  • How high of a dose of glucocorticoids and how long must you be on it before you need increased dose in perioperative period?
  • What do you do with insulin in the perioperative period?
  • When do you stop someone's Lovenox or Warfarin and what tests need to be performed when?
  • What about all these other rando drugs they are on? Do they need to be stopped and when?
• What is a "normal" postoperative fever and is Uworld/First Aid correct when it says that atelectasis is a major cause?
• What are the general rules for perioperative insulin management?
• What are some general checklists to mitigate postoperative pulmonary risk?

If yes, then see the .pdf attached to this thread. It's something I worked on over the course of several weeks while completing my 5th and final medicine sub-internship during the final month of medical school.

Of course, I would love if anyone has any clarifications or corrections to submit. That is part of the reason I'm posting this here.

Great post, this is very helpful (and I wish I would have had it in med school!) Check your inbox for a $10 Amazon gift card from SDN for this extremely helpful post! 🙂

 

[ProfMD]

A lot of this stuff is left to anesthesia, medicine, and cardiology.

A couple of things come to mind from a surgeons point of view:
1) Patients with multiple comorbidities should see PCP preop.
2) History of cardiac disease warrants visit to cardiologist preop.
3) "Clearance" for surgery is a misnomer - it's really risk stratification / medical optimization. The point is to give an idea of the medical risks of surgery (maybe surgery should not be done) and optimizing the patient's medical condition preop.
4) When to stop anticoagulants / antiplatelets depends on procedure and why patient is taking them. Generally, aspirin should be stopped 7 days preop - no labs. Warfarin should be stopped 5 days preop and can be followed with INR. Depending on why patient is on warfarin, they may need a heparin bridge to surgery.

Overall, though, I think this is a nice summary that OP posted.

 

[JustPlainBill]

The AAFP has an entire article complete with algorithm recently (within the last 5 years) addressing this as does Tarrascon's pocket Medicine and pocket Family Medicine books -- in actual practice, the surgeon usually tells the PCP what they need/want, then it's up to you to assess the basics -- cardiovascular/pulmonary and any other special things for your particular patient -- and you are NEVER giving "clearance" -- you are stating that the patient presents an average or above average risk for the proposed surgery or stating that they need to be seen by (insert specialist here) for their opinion before proceeding with the proposed surgery. It's usually billed as a 15 minute office consult, NOT a 99213/99214/99202/99203 code....

your mileage may vary, no warranties expressed or implied, car driven by a professional driver on a closed track.....

 

[sliceofbread136]

These posts are really great and I wish I had them back in third year. I hope you keep making them!

Anyone have insight as to if anything here really changes when clearing a child for surgery? I'm guessing criteria is pretty similar.

 

[bannie22]

Not safe anyway. Legally still need to have anesthesia clear. Unless wanna risk unnecessary lawsuits.

But probably good read for anesthesia, but they probably have their own protocols at each institution

 

[cbrons]

Not safe anyway. Legally still need to have anesthesia clear. Unless wanna risk unnecessary lawsuits.

But probably good read for anesthesia, but they probably have their own protocols at each institution

People are sent to their primary physician for preop exams

 

[Redpancreas]

Bump because I think this guide is amazing. Also, I read that if you need emergent surgery (ex-lap), you should use FFP if warfarin is 2.1 or something like that.

 

[cbrons]

Bump because I think this guide is amazing.

Thanks. I just updated the file.