Preoperative medical evaluation of the adult healthy patient

Preoperative medical evaluation of the adult healthy patient

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Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Preoperative medical evaluation of the adult healthy patient
Author
Gerald W Smetana, MD

Section Editors
Andrew D Auerbach, MD, MPH
Natalie F Holt, MD, MPH

Deputy Editor
Lee Park, MD, MPH

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2016. | This topic last updated: Jul 27, 2016.
INTRODUCTION — Clinicians are often asked to evaluate a patient prior to surgery. The medical
consultant may be seeing the patient at the request of the surgeon or may be the primary care clinician
assessing the patient prior to consideration of a surgical referral. The goal of the evaluation of the
healthy patient is to detect unrecognized disease and risk factors that may increase the risk of surgery
above baseline and to propose strategies to reduce this risk.
The evaluation of healthy patients prior to surgery is reviewed here. Preoperative assessments for
specific systems issues and surgical procedures are discussed separately. (See "Evaluation of cardiac
risk prior to noncardiac surgery" and "Perioperative medication management" and "Overview of the
principles of medical consultation and perioperative medicine" and "Evaluation of preoperative
pulmonary risk".)
CLINICAL EVALUATION — In general, the overall risk of surgery is extremely low in healthy individuals.
Therefore, the ability to stratify risk by commonly performed evaluations is limited.

Screening questionnaire — Screening questions appear on many standard institutional preoperative
evaluation forms. One validated screening instrument, derived from 100 patients, comprises 17
questions that allowed nurses to identify those patients who would benefit from a formal preoperative
evaluation by an anesthesiologist (table 1) [1]. The questions chosen for this questionnaire were devised
to detect preexisting conditions shown to be associated with perioperative adverse events.
Age — A number of commonly employed and validated indices consider age as a minor component of
preoperative coronary risk. (See "Evaluation of cardiac risk prior to noncardiac surgery".)
Some studies have found a small increased risk of surgery associated with advancing age [2,3]. In a
review of 50,000 older adult patients, for example, the risk of mortality with elective surgery increased
from 1.3 percent for those under 60 years of age to 11.3 percent in the 80- to 89-year-old age group [3].
Among 1.2 million Medicare patients undergoing elective surgery, mortality risk increased linearly with
age for most surgical procedures [4]. Operative mortality for patients 80 years and older was more than
twice that of patients 65 to 69 years old. However, age was not a significant predictor of cardiac
complications after multivariable analysis in the cohort of patients used to derive a revised cardiac risk
index [5].
In addition to the minor influence of age on perioperative cardiac risk, there is more robust literature
supporting age as an independent risk factor for postoperative pulmonary complications. Age was one of
the most important patient-related predictors of pulmonary risk, even after adjusting for common
age-related comorbidities, in a systematic review [6]. (See "Evaluation of preoperative pulmonary risk".)
By contrast, some studies have found little relation between age and mortality rates due to surgery. One
study reported the outcomes of surgery in 795 patients over 90 years of age [7]. No patients were Class
I as classified by the American Society of Anesthesiologists (ASA) physical status classification (table 2);
80 percent were ASA Class III or greater. Despite higher perioperative mortality rates in older adults,

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survival at two years was no different than the actuarial survival in matched patients not undergoing
surgery [7]. A larger study of 4315 patients also found a higher perioperative complication and mortality
rate in older individuals, but the mortality rate was low [8]. Among 31 patients age 100 years and older
undergoing surgery requiring anesthesia, perioperative and one-year mortality rates were similar to
matched peers from the general population [9].
After adjusting for comorbidities more common with age, the impact of age on perioperative outcomes is
modest. Much of the risk associated with age is due to increasing numbers of comorbidities, which may
include cognitive impairment, functional impairment, malnutrition, and frailty [10]. Geriatric patients may
benefit from preoperative assessments in those areas, but age should not be used as the sole criterion
to guide preoperative testing or to withhold a surgical procedure [11]. A risk calculator developed by the
American College of Surgeons National Surgery Quality Improvement Program may be helpful in
assessing preoperative risk in an older patient.
Exercise capacity — All patients should be asked about their exercise capacity as part of the
preoperative evaluation. Exercise capacity is an important determinant of overall perioperative risk;
patients with good exercise tolerance generally have low risk. (See "Evaluation of cardiac risk prior to
noncardiac surgery", section on 'Initial preoperative evaluation'.)
The American College of Cardiology/American Heart Association guideline on preoperative cardiac
evaluation recommends no testing for patients with good exercise capacity (at least 4 metabolic
equivalents [METs]) regardless of the risk of the planned procedure (algorithm 1) [12]. Patients’ ability to
expend ≥4 METs can be assessed by estimates from activities of daily living; activities that expend ≥4
METS include the ability to climb up a flight of stairs, walk up a hill, walk at ground level at 4 miles per
hour, or perform heavy work around the house [12].
Alternatively, more formal activity scales can be used. An observational study of 87 patients found that,
compared with the Duke Activity Status Index, subjective assessment by clinicians generally
underestimated exercise capacity [13].
In general, healthy patients who can perform these activities as part of their daily routine have a low risk
for major postoperative complications. This was illustrated in a study of 600 consecutive patients
undergoing major surgery [14]. The investigators defined poor exercise capacity as the inability to either

walk four blocks or climb two flights of stairs. Patients reporting poor exercise capacity had twice as
many serious postoperative complications as those who reported good exercise capacity (20 versus 10
percent, respectively). There was also a difference in cardiovascular complications (10 versus 5
percent), but not in total pulmonary complications (9 versus 6 percent).
The importance of functional capacity was confirmed objectively in another report of 847 patients
undergoing elective abdominal surgery [15]. In this study, poor exercise capacity, confirmed by
cardiopulmonary exercise testing, was a stronger predictor of all-cause mortality than any of the
conventional cardiac risk factors of the Revised Cardiac Risk Index.
Medication use — Clinicians should obtain a history of medication use for all patients before surgery
and should specifically inquire about over-the-counter, complementary, and alternative medications.
Aspirin, ibuprofen, and other nonsteroidal antiinflammatory drugs (NSAIDs) are associated with an
increased risk of perioperative bleeding. Specific inquiry about use of complementary and alternative
medications should also be part of the preoperative assessment. A detailed discussion of perioperative
medication management is presented separately. (See "Perioperative medication management".)
Obesity — Contrary to popular belief, in noncardiac surgery, obesity is not a risk factor for most major
adverse postoperative outcomes, with the exception of pulmonary embolism. None of the published and
widely disseminated cardiac risk indices for noncardiac surgery include obesity as a risk factor for
postoperative cardiac complications.

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Representative studies related to postoperative mortality in noncardiac surgery include:
● In a matched case control study of 1962 patients undergoing noncardiac surgery, obesity was not
associated with increased mortality (1.1 percent in obese patients versus 1.2 percent in controls)

[16].
● In a large, multi-institutional, prospective cohort of 118,707 patients undergoing non-bariatric
general surgery, obesity was inversely associated with postoperative mortality (odds ratio [OR]
0.85, 95% CI 0.75-0.99), a phenomenon termed the “obesity paradox” [17]. The authors suggest
that the obese state carries a low-grade, chronic inflammatory that may be “primed” to mount an
appropriate inflammatory and immune response to the stress of surgery, in addition to supplying
more nutritional reserve.
Other studies relating to complications in noncardiac surgery found that obesity increases rates for
wound infections but has no effect on other postoperative complications except for postoperative deep
venous thrombosis and pulmonary embolism [6,18-22]. (See "Prevention of venous thromboembolic
disease in surgical patients".)
However, in cardiac surgery, some studies have shown higher complication rates for obese patients,
including increased hospital stay [23], wound infections [23,24], prolonged mechanical ventilation [24],
and atrial arrhythmias [24,25].
Obstructive sleep apnea — Given the increased risks of perioperative morbidity and the potential for
altered anesthetic management, it is reasonable to screen patients for obstructive sleep apnea (OSA)
before surgery with one of several validated screening instruments. OSA increases the risk for
postoperative medical complications including hypoxemia, respiratory failure, unplanned reintubation,
and intensive care unit (ICU) transfer [26]. Most patients with OSA are undiagnosed. The prevalence of
previously undetected OSA is particularly high in patients preparing for bariatric surgery. A detailed
discussion of the perioperative risks and the role of screening for OSA is presented elsewhere. (See
"Surgical risk and the preoperative evaluation and management of adults with obstructive sleep apnea".)
Alcohol misuse — Patients who misuse alcohol on a regular basis have an increased risk for
postoperative complications [27]. Screening for alcohol misuse before surgery will identify a subset of
patients at increased risk for postoperative medical complications. While the benefit of directed alcohol
cessation programs before surgery is not well-established in the literature, there is little apparent risk to
such a strategy. The preoperative period also serves as an opportunity to identify patients who misuse
alcohol and are candidates for intervention as part of primary care follow-up after surgery. Pending
further study, it is reasonable to screen all patients for alcohol misuse before elective major surgery.
In a study of 9176 male US veterans, a screening questionnaire for alcohol misuse administered at any

time within one year before surgery accurately stratified risk of postoperative complications [28]. There
was a continuous relationship between postoperative complications and risk scores using the Alcohol
Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire (table 3). Surgical site
infections, other infections, and cardiopulmonary complications each increased across the strata of risk
groups based on alcohol use patterns. A similarly conducted trial of the AUDIT-C questionnaire before
total joint arthroplasty revealed comparable results [29]. Patients with high AUDIT-C scores (9 to 12 of
12 possible points) within the year before surgery also have longer lengths of stay, more ICU days, and
higher unplanned reoperation rates [30].
Most trials of alcohol cessation interventions have been conducted in the nonoperative setting; a small
study in patients undergoing colorectal surgery reported a beneficial effect of alcohol screening on
postoperative complications [31]. The optimal period of cessation is unknown but at least four weeks of
abstinence are required to reverse selected physiologic abnormalities [27].

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Illicit drug use — In order to provide appropriate perioperative care, it is helpful to ask patients about
illicit drug use [32]. Patients with chronic opioid use may have developed tolerance and require higher
than usual doses in the intraoperative and postoperative period. Patients who abuse opioids,
barbiturates, or amphetamines are at risk for drug withdrawal in the postoperative period. (See
"Substance use disorder: Principles for recognition and assessment in general medical care".)
Smoking — Evaluating tobacco use and offering strategies to quit smoking may reduce postoperative
morbidity and mortality, as current smokers have an increased risk for postoperative complications.
Smoking cessation prior to surgery may reduce the risk of postoperative complications, and longer
periods of smoking cessation may be even more effective. Smokers should be encouraged to quit

immediately preoperatively. (See "Strategies to reduce postoperative pulmonary complications in adults",
section on 'Smoking cessation' and "Overview of smoking cessation management in adults" and
"Behavioral approaches to smoking cessation".)
In cohort and case-control studies, preoperative smoking has been associated with an increased risk of
postoperative complications, including general morbidity (relative risk [RR] 1.52, 95% CI 1.33-1.74),
wound complications (RR 2.15, 95% CI 1.87-2.49), general infections (RR 1.54, 95% CI 1.32-1.79),
pulmonary complications (RR 1.73, 95% CI 1.35-2.23), neurological complications (RR 1.38, 95% CI
1.01-1.88), and admission to an ICU (RR 1.60, 95% CI 1.14-2.25) [33]. (See "Evaluation of preoperative
pulmonary risk", section on 'Smoking'.)
Personal or family history of anesthetic complications — Malignant hyperthermia is a rare
complication of anesthetic administration that is inherited in an autosomal dominant fashion. Due to the
morbidity and potential mortality associated with this condition, the preoperative history should include
questioning about either a personal or family history of complications from anesthesia. (See
"Susceptibility to malignant hyperthermia: Evaluation and management" and "Malignant hyperthermia:
Clinical diagnosis and management of acute crisis".)
LABORATORY EVALUATION — Several review articles in perioperative consultation and most local
institutional policies support a selective approach to preoperative testing [34-40]. A practice advisory
from the American Society of Anesthesiologists (ASA) and a safety guideline from the Association of
Anaesthetists of Great Britain and Ireland recommend against routine preoperative laboratory testing in
the absence of clinical indications [40,41].
Rationale for selective testing — The prevalence of unrecognized disease that influences surgical risk
is low in healthy individuals. Nevertheless, clinicians often perform laboratory tests in this group of
patients out of habit and medicolegal concern, with little benefit and a high incidence of false-positive
results. Representative studies that have addressed this issue include:
● In a trial of 1061 ambulatory surgical patients randomly assigned to preoperative testing or no
testing, there was no difference in perioperative adverse events or events within 30 days of
ambulatory surgery [42]. Patients assigned to testing could receive a complete blood count,
electrolytes, blood glucose, creatinine, electrocardiogram (ECG), and/or chest radiograph, based
on the Ontario Preoperative Testing Grid.
● Medical consultants commonly see patients before planned cataract surgery. In many institutions,

guidelines still require routine laboratory testing despite compelling evidence showing no benefit of
such testing. A systematic review of three randomized trials of testing versus no testing in a total of
21,531 cataract surgeries found that adverse events did not differ between the two groups [43].
Institutions may safely eliminate a requirement for routine laboratory tests before cataract surgery.
● In a retrospective study of 2000 patients undergoing elective surgery, 60 percent of routinely
ordered tests would not have been performed if testing had only been done for recognizable
indications; only 0.22 percent of these revealed abnormalities that might influence perioperative

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management [34]. Further chart review determined that these abnormalities were not acted upon,
nor did they have adverse surgical consequences.
● One report found that only 10 routine laboratory test results in 3782 patients required treatment;
just one of these required pharmacologic treatment [44]. In a prospective study of 1363 patients for
whom laboratory testing was performed at the discretion of the perioperative clinician, only an
abnormal ECG predicted postoperative complications. Abnormalities in commonly performed blood
test and chest radiography had no predictive value [45].
● Investigators performed a retrospective review of 73,596 patients undergoing elective hernia repair
using the National Surgical Quality Improvement Program (NSQIP) database [46]. Preoperative
tests were performed in 63.8 percent of patients; 61.6 percent of these patients had at least one
abnormal test result. Among patients with no accepted medical indication for testing, 54 percent
nonetheless received at least one test. After adjustment for demographics, comorbidities, and
procedure characteristics, neither preoperative testing nor the finding of an abnormal test result
were associated with adverse postoperative outcomes.

Predictive value — There are several arguments for avoiding routine preoperative tests. Normal test
values are usually arbitrarily defined as those occurring within two standard deviations from the mean,
thereby ensuring that 5 percent of healthy individuals who have a single screening test will have an
abnormal result. As more tests are ordered, the likelihood of a false-positive test increases; a screening
panel containing 20 independent tests in a patient with no disease will yield at least one abnormal result
64 percent of the time (table 4).
Thus, the predictive value of abnormal test results is low in healthy patients with a low prevalence of
disease (table 5). Aside from possibly causing patient alarm, the additional testing prompted by falsepositive screening tests leads to unnecessary costs, risks, and a potential delay of surgery. In addition,
clinicians often fail to act upon abnormal test results from routine preoperative testing, thereby creating
an additional medicolegal risk.
A review of studies of routine preoperative testing pooled data and estimated the incidence of
abnormalities that affect patient management and the positive and negative likelihood ratios for a
postoperative complication (table 6) [35]. For nearly all potential laboratory studies, a normal test did not
substantially reduce the likelihood of a postoperative complication (the negative likelihood ratio
approached 1.0). Positive likelihood ratios were modest, and they exceeded 3.0 for only three tests
(hemoglobin, renal function, and electrolytes); however, clinical evaluation can predict most patients with
an abnormal result. This was illustrated by the low incidence of a change in preoperative management
based on an abnormal test result (0 to 3 percent).
Timing of laboratory testing — When laboratory tests are felt to be necessary, it is reasonable to use
test results that were performed and were normal within the past four months, unless there has been an
interim change in clinical status. The validity of this approach was illustrated in an observational study
which investigated the usefulness of 7549 preoperative tests performed at the time of admission in 1109
patients undergoing elective surgery [37]. In 47 percent of cases, the same tests had been performed
within the previous year. When repeated at admission:
● Of 3096 previously normal tests (performed a median of two months prior to admission), only 13
(0.4 percent) values were outside a range considered acceptable for surgery, and most of these
patients had a change in clinical history that predicted the abnormality.
● Of 461 previously abnormal tests, when repeated at admission, only 78 (17 percent) remained
outside a range considered acceptable for surgery, suggesting that it is useful to repeat abnormal
tests in the immediate preoperative period.

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Laboratory studies — While preoperative laboratory testing is not routinely indicated, selective testing
is appropriate in specific circumstances, including patients with known underlying diseases or risk factors
that would affect operative management or increase risk, and specific high-risk surgical procedures [38].
Specific laboratory studies commonly ordered for preoperative evaluation include a complete blood
count, electrolytes, renal function, blood glucose, liver function studies, hemostasis evaluation, and
urinalysis. These tests are discussed below with indications for their use in specific populations and
surgeries.
Complete blood count
● Hemoglobin/hematocrit – A baseline hemoglobin measurement is suggested for all patients 65
years of age or older who are undergoing major surgery and for younger patients undergoing major
surgery that is expected to result in significant blood loss. By contrast, hemoglobin measurement is
not necessary for those undergoing minor surgery unless the history suggests anemia.
Anemia is present in approximately 1 percent of asymptomatic patients; surgically significant
anemia has an even lower prevalence [34]. However, anemia is common following major surgery
and the preoperative hemoglobin level predicts postoperative mortality. As an example, a large
observational study of older veterans (n = 310,311, age ≥65 years) found an increase in 30-day
postoperative mortality for patients with mildly abnormal preoperative hematocrits undergoing major
noncardiac surgery, even in the absence of significant blood loss [47]. Adjusted mortality increased
by 1.6 percent (95% CI 1.1 to 2.2 percent) for every one percentage point increase or decrease
from a normal hematocrit, defined as 39.0 to 53.9 percent.
The data cannot distinguish whether an abnormal hematocrit serves as a marker for coexistent

disease that increases mortality risk, or whether the anemia itself increases physiologic stresses
and therefore complication rates.
The observation that outcomes do not differ for patients undergoing hip surgery who were randomly
assigned to either liberal or restrictive transfusion policies suggests that anemia is a marker for risk,
rather than the cause of morbidity [48]. It remains unclear if the increased risk due to anemia is
modifiable by interventions aimed at correcting the hematocrit.
● White blood cell count and platelets – The frequency of significant unsuspected white blood cell
or platelet abnormalities is low [34]. It is reasonable to measure platelet count when neuraxial
anesthesia (spinal or epidural) is planned. Unlike the hemoglobin concentration, however, there is
little rationale to support baseline testing of either. Nevertheless, obtaining a complete blood count,
including white count and platelet measurement, can be recommended if the cost is not
substantially greater than the cost of a hemoglobin concentration alone. There may be some costs
incurred due to follow-up of false-positive results; however, with respect to platelet counts, these
costs do not appear to be substantial [49].
Renal function — It is appropriate to obtain a serum creatinine concentration in patients over the
age of 50 undergoing intermediate- or high-risk surgery, although there is no clear consensus on this
point. It should also be ordered when hypotension is likely, or when nephrotoxic medications will be
used.
Mild to moderate renal impairment is usually asymptomatic; the prevalence of an elevated creatinine
among asymptomatic patients with no history of renal disease is only 0.2 percent [34,50]. However, the
prevalence increases with age. In one study, for example, the prevalence among unselected patients
aged 46 to 60 was 9.8 percent [51].
In the revised cardiac risk index, a serum creatinine >2.0 mg/dL (177 micromol/L) was one of six
independent factors that predicted postoperative cardiac complications [5]. Renal insufficiency is also an

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independent risk factor for postoperative pulmonary complications [6] and a major predictor of
postoperative mortality [52]. Renal insufficiency necessitates dosage adjustment of some medications
that may be used perioperatively (eg, muscle relaxants).
Electrolytes — Routine electrolyte determinations are NOT recommended unless the patient has a
history that increases the likelihood of an abnormality. The frequency of unexpected electrolyte
abnormalities is low (0.6 percent in one report) [34]. While preoperative hypernatremia is associated with
an increase in perioperative 30-day morbidity and mortality [53], the relationship between most
electrolyte derangements and operative morbidity is not clear. Furthermore, clinicians can predict most
abnormalities based on history (for example, current use of a diuretic, angiotensin-converting enzyme
[ACE] inhibitor, or angiotensin receptor blocker [ARB], or known chronic kidney disease).
Blood glucose — Routine measurement of blood glucose is NOT recommended for healthy
patients. Unexpected abnormal blood glucose results do not often influence perioperative management.
As an example, one study evaluated the benefit of routine laboratory testing in 1010 presumably healthy
patients undergoing cholecystectomy [50]. Eight patients had unexpected elevations in preoperative
serum glucose; only one of these patients developed significant postoperative hyperglycemia, and this
was not recognized until after total parenteral nutrition was started. No patient in this study benefited
from routine preoperative measurement of serum glucose.
Also, the frequency of glucose abnormalities increases with age; almost 25 percent of patients over age
60 had an abnormal value in one report [51]. Most controlled studies have not found a relationship
between operative risk and diabetes [2,51], except in patients undergoing vascular surgery or coronary
artery bypass grafting [54,55]. While the revised cardiac risk index identified diabetes as a risk factor for
postoperative cardiac complications, only patients with insulin-treated diabetes were at risk [5]. There is
no evidence that asymptomatic hyperglycemia, in a patient not previously known to have diabetes,
increases surgical risk. The rate of asymptomatic hyperglycemia in unselected surgical patients is low; in
one report, the incidence was only 1.2 percent [56].
Liver function tests — Routine liver enzyme testing is NOT recommended. Unexpected liver
enzyme abnormalities are uncommon, occurring in only 0.3 percent of patients in one series [44]. In a

pooled data analysis, only 0.1 percent of all routine preoperative liver function tests changed
preoperative management (table 6) [35]. In a study of the NSQIP database, among 25,149 patient with
no comorbidities, the relative risk for major postoperative complications among patients who received
preoperative liver function tests, when compared with those with no testing, approached one (RR 0.94,
95% CI 0.42-2.08) [46].
Severe liver function test abnormalities among patients with cirrhosis or acute liver disease are
associated with increased surgical morbidity and mortality, but no data suggest that mild abnormalities
among patients with no known liver disease have a similar impact [57]. Clinically significant liver disease
would most likely be suspected on the basis of the history and physical examination.
Tests of hemostasis — Routine preoperative tests of hemostasis are NOT recommended. If the
history, physical examination, and family history do not suggest the presence of a bleeding disorder, no
additional laboratory testing is required. If the evaluation suggests the presence of a bleeding disorder,
appropriate screening tests should be performed, including prothrombin time (PT), activated partial
thromboplastin time (aPTT), and platelet count [58]. For some bleeding disorders (eg, inherited platelet
disorder, hemophilia carrier), additional tests may be required to establish a diagnosis and identify the
degree of abnormality [58,59]. (See "Preoperative assessment of hemostasis".)
Unexpected significant abnormalities of the PT or PTT are uncommon [34,49]. Inherited coagulation
defects are quite rare. For example, the incidence of hemophilia A and B among men is 1:5000 and
1:30,000, respectively [60]. Nearly all of these cases would be evident based on clinical presentation

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prior to the preoperative medical evaluation. In addition, the relationship between an abnormal result and
the risk of perioperative hemorrhage is not well-defined but appears to be quite low, particularly in those

who are thought to have a low risk of hemorrhage on the basis of history and physical examination
[61,62]. Even among neurosurgical patients, for whom a small amount of unanticipated bleeding could
cause substantial morbidity, the medical history is the most useful screening test for bleeding diathesis.
In a study of 11,804 patients undergoing spinal or intracranial surgery, a medical history that suggested
risk for bleeding complications was substantially more sensitive that PT or PTT values in predicting need
for transfusion, unplanned reoperation, and mortality [63].
In a pooled data analysis, an abnormal PT had a positive likelihood ratio of 0 for predicting a
postoperative complication and a negative likelihood ratio of 1.01 (table 6); in no case did the finding of
an abnormal PT change patient management or modify the likelihood of a complication [35]. Similarly,
the bleeding time is not useful in assessing the risk of perioperative hemorrhage [64,65].
Urinalysis — Routine urinalysis is NOT recommended preoperatively for most surgical procedures.
The theoretical reason to obtain a preoperative urinalysis is detection of unsuspected urinary tract
infection. Urinary tract infections have the potential to cause bacteremia and postsurgical wound
infections, particularly with prosthetic surgery [66]. Patients with positive urinalysis and urine culture are
generally treated with antibiotics and proceed with surgery without delay [67]. However, it is unclear
whether a positive preoperative urinalysis and culture with subsequent antibiotic treatment prevent
postsurgical infection. One study found no difference in wound infection between patients with normal
and abnormal urinalysis [68]. Another study found that patients with asymptomatic urinary tract infection
detected by urinalysis had an increased risk of wound infection postoperatively, despite treatment [69].
A cost-effectiveness analysis estimated that 4.58 wound infections in nonprosthetic knee operations may
be prevented annually by the use of routine urinalysis, at a cost of $1,500,000 per wound infection
prevented [70].
Asymptomatic renal disease can be detected by measurement of serum creatinine in selected patients.
(See 'Renal function' above.)
Pregnancy testing — The knowledge that a woman is pregnant substantially changes perioperative
management. We suggest pregnancy testing in all reproductive-age women prior to surgery. The patient
may elect to cancel elective surgery, or may decide in collaboration with her clinicians to undertake a
different, lower-risk surgery than originally planned. In addition, anesthetic technique differs for pregnant
women, and there may be risks to the fetus if a pregnancy goes undetected before surgery and
anesthesia.

Guidelines in the United Kingdom recommend always asking about the possibility of pregnancy before
surgery and, if pregnancy is possible after history-taking, offering a pregnancy test [71,72]. The ASA
recommends that clinicians offer pregnancy testing for women of childbearing age if the results would
alter management [40]. While these guidelines provide some discretion in deciding which women to test,
it is often not possible to reliably exclude pregnancy based on medical history-taking alone [73]. Many
institutions require pregnancy testing for all reproductive age women before surgery. There is low risk to
this approach; false-positives are rare, testing is inexpensive, and the results return rapidly. (See
"Clinical manifestations and diagnosis of early pregnancy", section on 'Detection of hCG'.)
ELECTROCARDIOGRAM — We suggest NOT ordering an electrocardiogram (ECG) for asymptomatic
patients undergoing low-risk surgical procedures. ECGs have a low likelihood of changing perioperative
management in the absence of known cardiac disease. The prevalence of abnormal ECGs increases
with age [74]. Important ECG abnormalities in patients younger than 45 years with no known cardiac
disease are very infrequent.
The 2014 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines on

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Perioperative Cardiovascular Evaluation state that ECG is not useful in asymptomatic patients
undergoing low-risk procedures [75]. Similarly, the European Society of Cardiology 2014 preoperative
guidelines do not recommend ECG in patients without risk factors [76].
The 2014 ACC/AHA guidelines recommend a preoperative resting 12-lead ECG for patients with known
coronary artery disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease or
other significant structural heart disease, except for those undergoing low-risk surgery (risk of major
adverse cardiac event <1 percent) [75]. A preoperative resting ECG can also be considered for

asymptomatic patients undergoing surgery with elevated risk (risk of major adverse cardiac event ≥1
percent). Preoperative evaluation of patients with known cardiovascular disease or risk factors is
discussed in detail elsewhere. (See "Evaluation of cardiac risk prior to noncardiac surgery".)
It is uncertain whether the preoperative approach to obese patients should differ from that of the general
population in regard to ECGs. This is discussed separately. (See "Preanesthesia medical evaluation of
the obese patient", section on 'Screening for comorbidities'.)
CHEST RADIOGRAPH — While routine preoperative chest radiographs are not indicated, we agree
with the American College of Physicians (ACP) recommendation for chest radiographs in patients with
cardiopulmonary disease and those older than 50 years of age who are undergoing abdominal aortic
aneurysm surgery or upper abdominal/thoracic surgery [6]. Posteroanterior and lateral chest radiograph
is also suggested by the American Heart Association for patients with severe obesity (BMI ≥40 kg/m2)
[77]. In these patients, the chest radiograph may indicate undiagnosed heart failure, cardiac chamber
enlargement, or abnormal pulmonary vascularity suggestive of pulmonary hypertension, warranting
further cardiovascular investigation. The relationship between findings on chest radiograph and
perioperative morbidity are not well-defined in these populations, however, and studies are not available
that indicate that preoperative radiography changes perioperative outcomes. Thus, we do not suggest
routine chest radiographs in severely obese patients, unless additional criteria such as poor exercise
tolerance and risk factors for coronary artery disease are present.
Preoperative chest radiographs add little to the clinical evaluation in identifying patients at risk for
perioperative complications [39]. Abnormal findings on chest radiograph occur frequently and are more
prevalent in older patients [78]. Several systematic reviews and independent advisory organizations in
the United States and Europe recommend against routine chest radiography in healthy patients [79-82].
There is little evidence to support the use of a preoperative chest radiograph regardless of age unless
there is known or suspected cardiopulmonary disease from the history or physical examination. In a
meta-analysis of 21 studies of routine chest radiography, among a total of 14,390 routine chest
radiographs, there were 1444 abnormal studies [83]. Only 140 abnormal findings were unexpected, and
only 14 (0.1 percent) of all routine chest radiographs influenced management.
One study screened 905 surgical admissions for the presence of clinical factors that were thought to be
risk factors for an abnormal preoperative chest radiograph [84]. The risk factors included age over 60
years or clinical findings consistent with cardiac or pulmonary disease. No risk factors were evident in

368 patients; of these, only one (0.3 percent) had an abnormal chest radiograph, which did not affect the
surgery. On the other hand, 504 patients had identifiable risk factors; of these, 114 (22 percent) had
significant abnormalities on preoperative chest radiograph.
PULMONARY FUNCTION TESTS — Routine pulmonary function tests are NOT indicated for healthy
patients prior to surgery. (See "Evaluation of preoperative pulmonary risk".)
These tests generally should be reserved for patients who have dyspnea that remains unexplained after
careful clinical evaluation. Clinical findings are more predictive of the risk of postoperative pulmonary
complications than are spirometric results [85]. These findings include decreased breath sounds,
prolonged expiratory phase, rales, rhonchi, or wheezes.

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INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The
Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at
the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and
are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail
these topics to your patients. (You can also locate patient education articles on a variety of subjects by
searching on “patient info” and the keyword(s) of interest.)
● Basics topic (see "Patient information: Questions to ask if you are having surgery or a procedure
(The Basics)")

SUMMARY AND RECOMMENDATIONS — The overall risk of surgery is low in healthy individuals.
Preoperative tests usually lead to false-positive results, unnecessary costs, and a potential delay of
surgery. Preoperative tests should not be performed unless there is a clear clinical indication.
● A simple screening questionnaire can be helpful in the preoperative evaluation (table 1). Important
potential risk factors to discuss with the patient include age, exercise capacity, alcohol, smoking,
illicit drug use, and medication use. Obesity is not a risk factor for most major adverse
postoperative outcomes in patients undergoing noncardiac surgery, with the exception of
thromboembolic events. Clinicians should also inquire about personal or family history of
complications from anesthesia and screen for symptoms of obstructive sleep apnea (OSA). (See
'Clinical evaluation' above.)
● Routine preoperative laboratory tests have not been shown to improve patient outcomes among
healthy patients undergoing surgery. In addition, routine testing in healthy patients has poor
predictive value, leading to false-positive test results and/or increased medicolegal risk for not
following up on abnormal test results. (See 'Rationale for selective testing' above.)
● We suggest baseline hemoglobin measurement for all patients 65 years of age or older who are
undergoing major surgery and for younger patients undergoing surgery that is expected to result in
significant blood loss (Grade 2C). Hemoglobin measurement is not necessary for younger patients
undergoing minor surgery unless the history suggests anemia. For other healthy patients, we
suggest NOT performing routine hemoglobin, white blood count, or platelet measurements (Grade
2B). (See 'Complete blood count' above.)
● In the revised cardiac risk index, a serum creatinine >2.0 mg/dL (177 micromol/L) predicted
postoperative cardiac complications. We suggest NOT obtaining a serum creatinine concentration,
except in the following patients (Grade 2B) (see 'Renal function' above):
• Patients over the age of 50 undergoing intermediate or high risk surgery
• Younger patients suspected of having renal disease, when hypotension is likely during
surgery, or when nephrotoxic medications will be used
● We suggest NOT testing for serum electrolytes, blood glucose, liver function, hemostasis, or
urinalysis in the healthy preoperative patient (Grade 2B). We suggest pregnancy testing in all
reproductive age women prior to surgery, rather than use of history-taking alone to determine
pregnancy (Grade 2C). (See 'Laboratory studies' above.)

● We suggest NOT ordering an electrocardiogram (ECG) for asymptomatic patients undergoing
low-risk surgical procedures.

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According to the 2014 American College of Cardiology/American Heart Association (ACC/AHA)
guidelines, a resting 12-lead ECG should be part of the evaluation in patients with known coronary
artery disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, or other
significant structural heart disease, except for those undergoing low-risk surgery.
A preoperative resting ECG can be considered for asymptomatic patients undergoing surgery with
elevated risk (risk of major adverse cardiac event ≥1 percent). This is discussed in detail
elsewhere. (See 'Electrocardiogram' above and "Evaluation of cardiac risk prior to noncardiac
surgery", section on 'Initial preoperative evaluation'.)
● We suggest that clinicians NOT order routine preoperative chest radiographs or pulmonary function
tests in the healthy patient (Grade 2B). We suggest obtaining a preoperative chest radiograph in
patients with cardiopulmonary disease and those older than 50 years of age who are undergoing
abdominal aortic aneurysm surgery or upper abdominal/thoracic surgery (Grade 2C). (See 'Chest
radiograph' above and 'Pulmonary function tests' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
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Topic 4816 Version 51.0

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GRAPHICS
Preoperative medical evaluation questions for a healthy patient
Questions
1. Do you usually get chest pain or breathlessness when you climb up two flights of stairs
at normal speed?
2. Do you have kidney disease?
3. Has anyone in your family (blood relatives) had a problem following an anaesthetic?
4. Have you ever had a heart attack?
5. Have you ever been diagnosed with an irregular heartbeat?
6. Have you ever had a stroke?
7. If you have been put to sleep for an operation were there any anaesthetic problems?
8. Do you suffer from epilepsy or seizures?
9. Do you have any problems with pain, stiffness or arthritis in your neck or jaw?

10. Do you have thyroid disease?
11. Do you suffer from angina?
12. Do you have liver disease?
13. Have you ever been diagnosed with heart failure?
14. Do you suffer from asthma?
15. Do you have diabetes that requires insulin?
16. Do you have diabetes that requires tablets only?
17. Do you suffer from bronchitis?
Data from: Hilditch, WG, Asbury, AJ, Jack, E, McGrane, S. Validation of a pre-anaesthetic
screening questionnaire. Anaesthesia 2003; 58:874.
Graphic 66690 Version 1.0

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American Society of Anesthesiologists (ASA) Physical Status
Classification System
ASA 1

A normal healthy patient

ASA 2

A patient with mild systemic disease

ASA 3

A patient with severe systemic disease

ASA 4

A patient with severe systemic disease that is a constant threat to life

ASA 5

A moribund patient who is not expected to survive without the operation

ASA 6

A declared brain-dead patient whose organs are being removed for donor
purposes

ASA Physical Status Classification System is reprinted with permission of the American Society
of Anesthesiologists, 520 N. Northwest Highway, Park Ridge, Illinois 60068-2573.
Graphic 87504 Version 6.0

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Stepwise approach to perioperative cardiac assessment for

CAD

ACS: acute coronary syndrome; CABG: coronary artery bypass graft surgery; CAD: coronary
artery disease; CPG: clinical practice guideline; DASI: Duke Activity Status Index; GDMT:
guideline-directed therapy; HF: heart failure; MACE: major adverse cardiac event; MET:
metabolic equivalent; NB: no benefit; NSQIP: National Surgical Quality Improvement
Program; PCI: percutaneous coronary intervention; RCRI: Revised Cardiac Risk Index;
STEMI: ST elevation myocardial infarction; UA/NSTEMI: unstable angina/non-ST elevation

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myocardial infarction; VHD: valvular heart disease.
Reproduced from: Fleisher LA, Fleischmann KE, Auerbach AD. 2014 ACC/AHA Guideline on
Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac
Surgery: A Report of the American College of Cardiology/American Heart Association Task
Force on Practice Guidelines. J Am Coll Cardiol 2014. [Epub ahead of print]. Illustration used
with the permission of Elsevier Inc. All rights reserved.
Graphic 96563 Version 3.0

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AUDIT-C
Question #1: How often did you have a drink containing alcohol in
the past year?
• Never

(0 points)

• Monthly or less

(1 point)

• Two to four times a month

(2 points)

• Two to three times per week

(3 points)

• Four or more times a week

(4 points)

Question #2: How many drinks did you have on a typical day when
you were drinking in the past year?
• 1 or 2

(0 points)

• 3 or 4

(1 point)

• 5 or 6

(2 points)

• 7 to 9

(3 points)

• 10 or more

(4 points)

Question #3: How often did you have six or more drinks on one
occasion in the past year?
• Never

(0 points)

• Less than monthly

(1 point)

• Monthly

(2 points)

• Weekly

(3 points)

• Daily or almost daily

(4 points)

The AUDIT-C is scored on a scale of 0 to 12 (scores of 0 reflect no alcohol use). In men, a
score of 4 or more is considered positive; in women, a score of 3 or more is considered
positive.
Graphic 53246 Version 4.0

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Probability of an abnormal screening test result
Number of independent tests

Probability of abnormal test

1

5 percent

2

10 percent

4

19 percent

6

26 percent

10

40 percent

20

64 percent

50

92 percent

Graphic 60009 Version 1.0

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Predictive value of positive test results
Prevalence of disease,
percent

Predictive value of positive test,
percent

0.1

1.9

1.0

16.1

2.0

27.9

5.0

50.0

50.0

95.0

Graphic 55083 Version 1.0

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Value of preoperative tests in influencing preoperative
management and predicting postoperative complications in
adults
Incidence of
abnormalities
Test

that influence
management,
percent

Positive
likelihood ratio

Negative
likelihood ratio

of
postoperative

of
postoperative

complication,

complication,

LR+

LR-

Hemoglobin

0.1

3.3

0.90

White blood cell
count

0.0

0.0

1.00

Platelet count

0.0

0.0

1.00

Prothrombin time
(PT)

0.0

0.0

1.01

Partial
thromboplastin
time (PTT)

0.1

1.7

0.86

Electrolytes

1.8

4.3*

0.80

Renal function

2.6

3.3

0.81

Glucose

0.5

1.6

0.85

Liver function
tests

0.1

NA**

NA**

Urinalysis

1.4

1.7

0.97

Electrocardiogram

2.6

1.6

0.96

Chest radiograph

3.0

2.5

0.72

*Although the LR+ value is higher for electrolytes than for other preoperative tests, most
of these patients could have been selectively identified as candidates for testing based on
clinical criteria. The authors therefore do not recommend routine measurement of
preoperative electrolytes.
**NA = Not available; no studies have reported the incidence of adverse events in a

cohort of healthy patients with normal or abnormal liver function tests.
Reproduced with permission from Smetana, GW, Macpherson, DS. The case against routine
preoperative laboratory testing. Med Clin North Am 2003; 87:7. Copyright © 2003 Elsevier
Science.
Graphic 75939 Version 2.0

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Contributor Disclosures
Gerald W Smetana, MD Nothing to disclose. Andrew D Auerbach, MD, MPH Nothing to disclose.
Natalie F Holt, MD, MPH Nothing to disclose. Lee Park, MD, MPH 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

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