2 Preoperative Assessment
and Perioperative
Management
Abstract
This chapter will provide an overview of
preoperative assessment as it relates to
plastic surgery. It will include
medication management and will review
periopera- tive antibiotic management.
The reader will be able to prepare
management plans for different
scenarios.
Keywords: preoperative assessment,
peri- operative management, DVT,
antibiotic prophylaxis, SCIP
Six Key Points
The Surgical Care Improvement
Project (SCIP) defines postoperative
events and makes recommendations
on perioperative management.
Superficial plastic surgery cases are
low risk.
Patients with cardiac stents should
remain on anticoagulation.
Smoking increases complications
fivefold.
Patients should stop smoking 8 weeks
prior to elective surgery.
Assess the risk of obstructive sleep
apnea.
Overview
While the preoperative workup can be
tailored to a specific problem, there are
general principles of perioperative
manage- ment that are useful for any
case. The Surgical Care Improvement
Project (SCIP) was created in 2003 as
an initiative of
the Centers for Disease Control and
Prevention (CDC) and Centers for
Medicare & Medicaid Services (CMS), and
has a defined goal to reduce surgical
morbidity and vmor- tality. It has defined
postoperative events and makes
recommendations on periopera- tive
management.
Questions
Case 1
Preoperative Assessment
1. What is considered low-risk
surgery? Superficial plastic surgery cases
and general breast surgery are considered
low-risk surgeries. Low-risk surgery can
become moderate risk surgery if general
anesthesia is required.
2.What are the revised cardiac
risk indicators?
Invasive surgery, ischemic heart disease,
heart failure, cerebrovascular accident
(CVA), creatinine greater than 2.0, and
diabetes mellitus requiring insulin.
3.Your patient was found to have a
cardiac condition and had stents
placed. Under what conditions do you
proceed with surgical intervention?
If a patient has had a previous balloon
angioplasty over 14 days ago, one can
proceed with surgery if the patient contin-
ues aspirin. If the patient has a bare-
metal stent, and it has been more than 6
weeks (ideally 3 months), the patient can
be taken to surgery with aspirin. If the
patient has had a drug-eluting stent,
nonurgent
6
 Preoperative Assessment and Perioperative Management

surgery should be postponed until after a
year, and then surgery can proceed if the
patient continues aspirin.
Medication Management
1. Your patient wants to know
which medications he can take
before surgery (Table 2.1). What do
you tell him?
Some medications can be taken up to
and including the day of surgery, some
should be taken until surgery but not
taken on the day of surgery, and some
should be stopped prior to surgery. These
are sum- marized in Table 2.1.
Pulmonary
1.Your patient is a smoker. What sorts
of perioperative pulmonary risks are
associated with smoking?
All complications (major and minor)
related to smoking are increased almost
fivefold
when compared with never smokers. Past
smokers are also at increased risk.1
2.How long should a patient have
quit smoking prior to surgery?
Ideally, a patient should have quit smoking
for at least 8 weeks prior to elective surgery.2
3.How do you verify the patient has
quit smoking prior to surgery?
One always has discussion with patients
regarding smoking prior to surgery. Identi-
fication and verification of smoking
cessation is a two-pronged approach:
direct discussion with the patient and a
serum cotinine test.
RATIONALE: A serum cotinine test can
be ordered either qualitatively or
quantita- tively. The quantitative test will
help dis- tinguish between an active
tobacco user and one who has recently
quit; it takes approximately 2 weeks for
serum cotinine to return to normal.

Table 2.1 Perioperative management of medications

Category Medication Indication Until surgery Day of
surgery
Heart failure Beta blockers Yes Yes
ACE/ARB Yes No
Diuretics Yes No
Hydralazine/nitrates
Anticoagulation Aspirin Primary prevention Yes Yes
of CAD/stroke
Stents Yes Yes
Clopidogrel Yes Yes
Prasugrel Yes Yes
Piclodipine Yes Yes
Oncologic Tamoxifen Stop 5 d before No
Aromatase Yes Yes
inhibitors
Diabetes Insulin (long acting) Yes No
Insulin (short Yes No
acting)
Psychiatric MAOI Stop 2 wk No
before
Abbreviations: ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker;
CAD, coronary artery disease; MAOI, monoamine oxidase inhibitor.
8 Preoperative Assessment and Perioperative Management
Active smokers have serum cotinine
greater than 14 ng/mL, recent smokers
have levels of 0.5 to 13.9 ng/mL, and
unex- posed people have serum cotinine
levels less than 0.05 ng/mL.3
4.How do you assess the risk
of obstructive sleep apnea
(OSA) in a patient?
I assess the risk of OSA with the STOP-
Bang score.
RATIONALE: The STOP-Bang score, pub-
lished in 2008 and 2012,4,5 is used to
assess risk of OSA. It assigns 1 point for
each answer of yes to the following
screening questions:
• Do you Snore?
• Are you Tired during the day?
• Witnessed Obstruction when
asleep?
• High blood Pressure?
• BMI greater than 35 kg/m2?
• Age older than 50 years?
• Neck size greater than 17 inches in
males and greater than 16 inches in
females?
• And male Gender?
A score of 0 to 2 is low risk, 3 to 4 is
inter- mediate risk, and greater than 5 is
high risk. A score of 6 or higher is most
predictive. The STOP-Bang questionnaire
has been validated in obese and morbidly
obese patients.6
Case 2
Perioperative Management
1.When do you start and
stop perioperative
antibiotics?
Antibiotics are given within one hour of
surgery and are discontinued within 48
hours after surgery.
RATIONALE: The SCIP measures include
postoperative infection as a surgical
complication. The recommendations are
to receive IV antibiotics within 1 hour of
incision, and antibiotics given more than
2 hours before incision or after incision
are both associated with greater rates of
wound infection.7 The criteria for antibi-
otic prophylaxis are that the antibiotic
should be safe, cost-effective, and broad
spectrum. Prophylactic antibiotics
should be discontinued within 48 hours
of surgical end time.
There is some controversy regarding
postoperative use of antibiotics. The
Amer- ican Society of Plastic Surgeons
notes that there are no good
recommendations regarding antibiotics
with the use of drains. Some studies have
shown that when postoperative antibiotics
are contin- ued longer than
recommended, antibiotic resistance is
more prevalent when infec- tion does
occur.
2. What is your intraoperative
and postoperative deep vein
thrombosis (DVT) prophylaxis
protocol?
DVT prophylaxis b egins with assessment
of risk, which is performed by calculating
the Caprini score (Fig. 2.1).
RATIONALE: The Caprini score is a
point system in which patient-specific
factors such as obesity, age, history, and
type and length of surgery are considered
and assigned points. A score of 0 to 1 is
low risk (2% incidence of DVT), 2 is
moderate risk (10–20% incidence), 3 to 4
is high risk (20–
40% incidence), and 5 is highest risk (40–
80%). Treatment for each score is
presented in Table 2.2.
Early ambulation is a mainstay of
pre- vention for all plastic surgery
patients and is undertaken as soon as it
is safe to do so surgically. In addition,
for body contouring patients,
enoxaparin is given for a 7- to 10-day
postoperative course.
 Preoperative Assessment and Perioperative Management

Fig. 2.1 Caprini score. The

Caprini score is a validated
method of predicting deep
vein thrombosis/pulmonary
embolism risk, and proposes
intervention based on
measured risk. (Adapted from
Caprini JA. Risk assessment
as a guide to thrombosis
pro- phylaxis. Curr Opin
Pulm Med
2010;16(5):448–452.)

Table 2.2 Caprini score risk stratification and recommendations

Caprini score Risk Prophylaxis
0–1 Low (2%) Early ambulation
2 Moderate (10–20%) Mechanical prophylaxis (sequential compression
device) OR chemoprophylaxis (heparin 5,000 units SQ
twice daily)
3–4 High (20–40%) Chemoprophylaxis (heparin or enoxaparin weight-based
and renally based dosing) ± mechanical prophylaxis
≥5 Highest (40–80%) Chemoprophylaxis (Lovenox is preferred, heparin
preferred with epidurals) AND mechanical prophylaxis
Abbreviation: SQ, subcutaneous.

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