Preoperative medical evaluation of the

healthy adult patient

Author: Gerald W Smetana, MD
Section Editors: Andrew D Auerbach, MD, MPH, Natalie F Holt, MD, MPH
Deputy Editor: Jane Givens, MD, MSCE

Contributor Disclosures

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

Literature review current through: Jan 2023. | This topic last updated: Aug 09, 2022.

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".)

● (See "Evaluation of perioperative pulmonary risk".)
● (See "Perioperative medication management".)
● (See "Overview of preoperative evaluation and preparation for
gynecologic surgery".)
● (See "Cataract in adults", section on 'Surgical planning'.)
CLINICAL EVALUATION

In general, the overall risk of surgery is extremely low in healthy adults.

Therefore, the ability to stratify risk by commonly performed evaluations is
limited.

Screening questionnaire — Screening questions appear on many standard

institutional preoperative evaluation forms. The purpose of these instruments
is to provide an estimate of perioperative risk and to identify patients who
need a preoperative clinician consultation. While many such screening
questionnaires exist, we use a questionnaire based upon the American
Association of Nurse Anesthesiology (AANA) preanesthesia questionnaire; it is
of a suitable length and captures most relevant elements of the preoperative
evaluation [1]. A more complex instrument, the electronic Personal
Assessment Questionnaire [ePAQ], has been validated for use as part of an
online preoperative screening process [2] and may be used if available.

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"). However, after adjusting for
comorbidities more common with age, the impact of age on perioperative
outcomes is modest. Much of the risk associated with older age is due to
increasing numbers of comorbidities, which may include cognitive
impairment, functional impairment, malnutrition, and frailty [3]. Older
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 [4]. Risk assessment in older patients is
reviewed elsewhere. (See "Anesthesia for the older adult", section on
'Preanesthesia consultation'.)
Some studies have found a small increased risk of surgery associated with
advancing age [5,6]. As examples:

● In a review of 50,000 older adult adults, 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 [6].

● Among 1.2 million Medicare patients undergoing elective surgery,

mortality risk increased linearly with age for most surgical procedures [7].
Operative mortality for patients 80 years and older was more than twice
that of patients 65 to 69 years old.

● In a systematic review evaluating mortality among older adults

undergoing emergency general surgeries, the overall 30-day mortality
among octogenarians was 26 percent, and higher compared with non-
octogenarians (odds ratio [OR] 4.07, 95% CI 2.40-6.89) [8].

By contrast, other studies have found little relation between age and surgical
mortality rates. As examples:

● One study reported the outcomes of surgery in 795 patients over 90

years of age [9]. No patients were Class I as classified by the American
Society of Anesthesiologists (ASA) physical status classification (table 1);
80 percent were ASA Class III or greater. Despite higher perioperative
mortality rates in older adults, survival at two years was no different than
the actuarial survival in matched patients not undergoing surgery.

● A larger study of 4315 patients also found a higher perioperative

complication and in-hospital mortality rate in individuals ≥80 years old,
but the mortality rate was low at 2.6 percent [10].

● 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 [11].

● In another study, 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 [12].

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. In a systematic review, age was one
of the most important patient-related predictors of pulmonary risk, even after
adjusting for common age-related comorbidities [13]. This is reviewed
elsewhere. (See "Evaluation of perioperative pulmonary risk".)

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".)

The American College of Cardiology/American Heart Association guideline on

preoperative cardiac evaluation recommends that patients with good exercise
capacity (at least 4 metabolic equivalents [METs]) do not require preoperative
testing, regardless of the risk of the planned procedure (algorithm 1) [14].
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.

However, a more formal assessment of functional capacity may more reliably

predict surgical risk [15,16], and we favor the use of a standardized
assessment and scoring system such as the Duke Activity Status Index (DASI)
rather than relying upon subjective self-reported functional capacity (table 2).
In the largest trial to formally evaluate the impact of functional capacity on
surgical outcomes, investigators in the Measurement of Exercise Tolerance
before Surgery (METS) trial compared scores on the standardized DASI
questionnaire with subjective self-reported functional capacity [16]. The DASI
instrument contains 12 questions related to activities of daily living as well as
more vigorous activity (table 2) [15]. In an adjusted analysis, subjectively
reported functional capacity did not predict death or myocardial infarction in
the first 30 days after surgery, whereas DASI scores were significantly
associated with these outcomes. (See "Evaluation of cardiac risk prior to
noncardiac surgery".)

In general, healthy patients with moderate (or better) functional capacity

have a low risk for major postoperative complications. This was illustrated in a
study of 600 consecutive patients undergoing major surgery [17]. 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 [18]. 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, herbal, and alternative medications. Aspirin,
ibuprofen, and other nonsteroidal antiinflammatory drugs (NSAIDs) are
associated with an increased risk of perioperative bleeding. 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.

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) [19].

● In a large, multi-institutional prospective cohort of 118,707 patients

undergoing non-bariatric general surgery, obesity was inversely
associated with postoperative mortality (OR 0.85, 95% CI 0.75-0.99), a
phenomenon termed the “obesity paradox” [20]. 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 [13,21-26]. (See "Prevention of venous
thromboembolic disease in adult nonorthopedic surgical patients".)
However, in cardiac surgery, some studies have shown higher complication
rates for patients with obesity, including increased hospital stay [27], wound
infections [27,28], prolonged mechanical ventilation [28], and atrial
arrhythmias [28,29].

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, such as the
STOP-Bang questionnaire (table 3). OSA increases the risk for postoperative
medical complications including hypoxemia, respiratory failure, unplanned
reintubation, and intensive care unit (ICU) transfer [30]. Most patients with
OSA are undiagnosed. The prevalence of previously undetected OSA is
particularly high in patients preparing for bariatric surgery. The ASA
recommends screening for OSA before noncardiac surgery [31]. A detailed
discussion of the indications and techniques for preoperative screening for
OSA is presented elsewhere. (See "Surgical risk and the preoperative
evaluation and management of adults with obstructive sleep apnea", section
on 'Whom to screen' and "Surgical risk and the preoperative evaluation and
management of adults with obstructive sleep apnea", section on 'Screening
questionnaires'.)

Alcohol misuse — Patients who misuse alcohol on a regular basis have an

increased risk for postoperative complications [32]. Pending further study, it
is reasonable to screen all patients for alcohol misuse before elective major
surgery. 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.

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 [33]. There was a continuous
relationship between postoperative complications and risk scores using the
Alcohol Use Disorders Identification Test-Consumption (AUDIT-C)
questionnaire (table 4). 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 [34]. 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 [35].

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 [36]. The optimal period of cessation is unknown but at least
four weeks of abstinence are required to reverse selected physiologic
abnormalities [32].

Illicit drug use — In order to provide appropriate perioperative care, it is

helpful to ask patients about illicit drug use [37]. Patients with chronic opioid
use may have developed tolerance and require higher than usual doses in the
intraoperative and postoperative period. Patients who use opioids,
barbiturates, or amphetamines are at risk for drug withdrawal in the
postoperative period. (See "Benzodiazepine poisoning and withdrawal" and
"Opioid withdrawal in the emergency setting" and "Alcohol withdrawal:
Epidemiology, clinical manifestations, course, assessment, and diagnosis".)
Smoking — Evaluating tobacco use and offering strategies to quit smoking
may reduce postoperative morbidity and mortality, as patients who smoke
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 are even more effective [38]. Those who
smoke should be encouraged to quit preoperatively. (See "Strategies to
reduce postoperative pulmonary complications in adults", section on
'Smoking cessation' and "Overview of prehabilitation for surgical patients",
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) [39]. (See "Evaluation of perioperative 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:
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 laboratory
testing [40-47]. 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 [46,48].

Rationale for selective testing — In healthy individuals, the prevalence of

unrecognized disease that influences surgical risk is low. Clinicians often
perform laboratory tests in this group of patients out of habit and
medicolegal concern [49,50]. However, there is 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 [51].

● 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 management [40]. Further chart review determined that
these abnormalities were not acted upon, nor did they have adverse
surgical consequences.

● In a prospective study of 1363 patients for whom laboratory testing was

performed at the discretion of the perioperative clinician, abnormalities
in commonly performed blood tests had no predictive value for surgical
complications [52].
 ● In a retrospective review using the National Surgical Quality
Improvement Program (NSQIP) database and including over 73,000
patients undergoing elective hernia repair, preoperative laboratory tests
were performed in 63.8 percent of patients; 61.6 percent of these
patients had at least one abnormal test result [53]. Among patients with
no accepted medical indication for testing, 54 percent received at least
one test. After adjustment for demographics, comorbidities, and
procedure characteristics, neither preoperative testing nor the finding of
an abnormal test result was associated with adverse postoperative
outcomes.

The value of routine preoperative laboratory testing in patients undergoing

ambulatory surgery is particularly low among ASA class 1 and 2 patients
(table 1). As an example, in a retrospective analysis using the NSQIP database
and including over 111,000 patients undergoing low-risk surgeries, 51.6
percent underwent preoperative testing; patients who received testing had
higher baseline rates of medical comorbidities [54]. Among those tested, 46.4
percent had at least one abnormal test result. The rates of perioperative
mortality, serious morbidity, and unplanned reoperation did not differ
between those who received preoperative testing and those who did not. In a
multivariable analysis (to adjust for differences in comorbidities),
preoperative laboratory testing was associated with a slightly increased risk
of surgical complications (odds ratio [OR] 1.28, CI 1.18-1.40) but had no
impact on mortality or serious morbidity.

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 5).

Thus, the predictive value of abnormal test results is low in healthy patients
with a low prevalence of disease (table 6). Aside from possibly causing patient
alarm, the additional testing prompted by false-positive 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 a 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 7) [41]. 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, kidney
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 preoperative laboratory tests are felt

to be necessary, it is reasonable to rely upon test results found to be normal
within the prior four months, unless there has been an interim change in a
patient's clinical status.

The validity of this approach was illustrated in an observational study of 1109

patients undergoing elective surgery who had 7549 preoperative laboratory
tests performed at admission; almost half of these tests had also been
performed within the previous year [43].
 ● Of previously normal tests (performed a median of two months prior to
admission), only 0.4 percent were outside the range considered
acceptable for surgery on repeat testing; most of these patients had a
change in clinical history that predicted the abnormality.

● Of previously abnormal tests, 17 percent remained outside the range

considered acceptable for surgery, suggesting that it is useful to repeat
only abnormal tests in the immediate preoperative period.

Other studies have not necessarily supported this approach, but issues with
study design limit their applicability. As an example, in a subsequent review of
the NSQIP database, 235,010 relatively healthy (ASA physical class status I or
II) patients undergoing elective surgery with normal preoperative blood test
results in the preceding three months were evaluated for 30-day
postoperative morbidity and mortality [55]. Patients were divided into
quintiles based on the time elapsed between preoperative blood testing and
surgery (<1 week, one to two weeks; two to four weeks; one to two months;
two to three months). Patients whose laboratory testing was performed less
than two weeks before surgery had better 30-day composite morbidity and
mortality outcomes compared with those that had laboratory testing
performed two to three months prior to surgery (OR 0.77; 95% CI 0.59-0.99).

However, methodologic flaws (eg, patients were not randomly assigned to

quintiles) and other residual confounders may have influenced the results of
the study. Thus, we do not feel that these findings change the
recommendation that normal tests obtained within four months
preoperatively do not need to be repeated unless there is a change in clinical
status.

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 [44]. 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 any patient 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 severe anemia or worsening of chronic,
stable anemia.

Preoperative anemia is common; a cohort study of more than 200,000

patients undergoing major non-cardiac surgery found preoperative
anemia (defined as a hematocrit of less than 39 percent in men and 36
percent in women) in 30 percent of cases [56]. Postoperative mortality at
30 days was higher in patients with anemia (OR 1.42, 95% CI 1.31-1.54).
The risk was similar among those with mild and moderate to severe
anemia. Similarly, in a retrospective analysis of almost 86,000 patients,
moderate or severe anemia (hemoglobin ≤9 g/dL) was associated with
higher 30-day postoperative mortality compared with patients with no or
mild anemia (OR 1.51, 95% CI 1.05-2.17) [57].

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 [58]. 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 [40]. 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 [59].

Kidney 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.
Creatinine should also be ordered when hypotension is likely, or when
nephrotoxic medications will be used.

Mild to moderate kidney impairment is usually asymptomatic. The prevalence

of an elevated creatinine among asymptomatic patients with no history of
kidney disease is only 0.2 percent [40,60]. However, the prevalence increases
with age. In one study, for example, the prevalence among unselected
patients aged 46 to 60 was 9.8 percent [61].

In the revised cardiac risk index (table 8), a serum creatinine >2.0 mg/dL (177
micromol/L) was one of six independent factors that predicted postoperative
cardiac complications [12]. Chronic kidney disease is also an independent risk
factor for postoperative pulmonary complications [13] and a major predictor
of postoperative mortality [62]. Impaired kidney function necessitates dosage
adjustment of some medications that may be used perioperatively (eg,
muscle relaxants). (See "Evaluation of cardiac risk prior to noncardiac
surgery", section on 'Risk assessment' and "Evaluation of perioperative
pulmonary risk".)

Electrolytes — Routine electrolyte determinations are NOT recommended

unless the patient has a history that increases the likelihood of an
abnormality, such as patients who take diuretics, angiotensin-converting
enzyme (ACE) inhibitors, or angiotensin receptor blockers (ARBs). In healthy
adults, the frequency of unexpected electrolyte abnormalities is low (0.6
percent in one report) [40]. While preoperative hypernatremia is associated
with an increase in perioperative 30-day morbidity and mortality [63], 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, ACE inhibitor, or 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 [60]. 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 [61].
Most controlled studies have not found a relationship between operative risk
and diabetes [5,61], except in patients undergoing vascular surgery or
coronary artery bypass grafting [64-66]. 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 [12]. There is limited
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 [67]. A systematic review examined the
relationship between preoperative blood glucose and A1c values in patients
without known diabetes and postoperative complications after noncardiac
surgery [66]. Among 22 eligible studies, no high-quality tests supported a role
for routine preoperative screening in otherwise healthy patients. Exceptions
were an increased risk of cardiac complications after vascular surgery and an
increased risk for infectious complications after orthopedic surgery, among
patients with abnormal preoperative blood glucose or A1c.

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 [68]. In a pooled data analysis, only 0.1
percent of all routine preoperative liver function tests changed preoperative
management (table 7) [41]. 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) [53].

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 [69]. 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
[70]. 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 [70,71]. (See "Preoperative assessment of
hemostasis".)

Unexpected significant abnormalities of the PT or PTT are uncommon [40,59].

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 [72].
Nearly all of these cases would be evident based on clinical presentation 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 [73,74]. 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 [75].
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 7); in no case did the finding of an abnormal PT change patient
management or modify the likelihood of a complication [41]. Similarly, the
bleeding time is not useful in assessing the risk of perioperative hemorrhage
[76,77].

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 [78]. Patients with positive
urinalysis and urine culture are generally treated with antibiotics and proceed
with surgery without delay [79]. 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 [80]. Another
study found that patients with asymptomatic urinary tract infection detected
by urinalysis had an increased risk of wound infection postoperatively,
despite treatment [81].

In a prospective study of 4663 patients undergoing joint replacement surgery

at a single institution, the impact of eliminating the requirement for routine
preoperative urinalyses was investigated [82]. While 96 percent fewer
urinalyses were performed after the policy change, there was no increase in
rates of surgical site infection or catheter-associated urinary tract infection.

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 USD $1,500,000 per wound infection prevented
[83]. In a subsequent analysis evaluating United States insurance claims over
a 10-year period, 89 percent of preprocedural urinalyses were considered
inappropriate, costing over $48 million, with an additional $4.8 million spent
on antibiotic treatment [84].

Pregnancy testing — Pregnancy substantially changes perioperative

management. We suggest pregnancy testing in all females of reproductive
potential prior to surgery. In collaboration with treating clinicians, the
pregnant patient may choose to cancel elective surgery or elect a different,
lower-risk surgery than originally planned. In addition, anesthetic technique
differs in pregnancy, 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 [85,86]. The ASA recommends that
clinicians offer pregnancy testing for females of childbearing age if the results
would alter management [46]. While these guidelines provide some
discretion in deciding which individuals to test, it is often not possible to
reliably exclude pregnancy based on medical history-taking alone [87]. Many
institutions require pregnancy testing for all reproductive age females 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 human chorionic
gonadotropin'.)

COVID-19 screening and testing — Patients scheduled for elective surgery

should be screened for exposure to and symptoms of coronavirus disease
2019 (COVID-19). Symptomatic patients should be referred for additional
clinical assessment. (See "COVID-19: Evaluation of adults with acute illness in
the outpatient setting", section on 'Initial clinical evaluation'.)
Protocols for routine preoperative testing vary by institution and geographic
region [88], although a 2021 joint statement published by the ASA and the
Anesthesia Patient Safety Foundation recommends that all patients
scheduled for elective surgery should undergo preoperative polymerase
chain reaction (PCR) testing for COVID-19 [89]. Ideally, this testing should be
performed no longer than 72 hours before surgery and applies to all
asymptomatic patients regardless of vaccination status. (See "COVID-19:
Perioperative risk assessment and anesthetic considerations, including airway
management and infection control", section on 'Preoperative evaluation
during the pandemic' and "COVID-19: Diagnosis", section on 'Selected
asymptomatic individuals'.)

ELECTROCARDIOGRAM

We suggest not ordering an electrocardiogram (ECG) for asymptomatic

patients undergoing low-risk surgical procedures (see "Preoperative
evaluation for anesthesia for noncardiac surgery", section on 'Surgical risk').
ECGs have a low likelihood of changing perioperative management in the
absence of known cardiac disease. The prevalence of abnormal ECGs
increases with age [90]. 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 Perioperative Cardiovascular Evaluation state that
ECGs are not useful in asymptomatic patients undergoing low-risk procedures
[91]. Similarly, the European Society of Cardiology 2014 preoperative
guidelines do not recommend obtaining ECGs in patients without risk factors
[92].

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) (table 9) [91]. 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
cardiovascular disease risk factors is discussed in detail elsewhere. (See
"Evaluation of cardiac risk prior to noncardiac surgery".)

The 2009 AHA Scientific Advisory on Cardiovascular Evaluation and

Management of Severely Obese Patients Undergoing Surgery states that it is
reasonable to obtain a 12-lead ECG prior to surgery in patients with class III
obesity (body mass index ≥40 kg/m2) with at least one risk factor for coronary
heart disease (diabetes, smoking, hypertension, or hyperlipidemia) or poor
exercise tolerance [93]. This is discussed separately. (See "Preanesthesia
medical evaluation of the patient with obesity", section on 'Cardiovascular
disease'.)

CHEST RADIOGRAPHS

We suggest not obtaining routine preoperative chest radiographs in healthy

adults, even before high-risk non-cardiothoracic surgery, in the absence of
active cardiopulmonary disease (eg, a change in baseline symptoms in
patients with established cardiopulmonary disease) or symptoms
(algorithm 2) (see 'Exercise capacity' above). This is consistent with the
American Society of Anesthesiologists practice advisory [46]. In addition,
several systematic reviews and independent advisory organizations in the
United States and Europe recommend against routine chest radiography in
healthy patients [94-97].
Preoperative chest radiographs add little to the clinical evaluation in
identifying patients at risk for perioperative complications [45]. Abnormal
findings on chest radiograph occur frequently and are more prevalent in
older patients [98]. There is little evidence to support the use of preoperative
chest radiographs, regardless of age, unless there is known or suspected
cardiopulmonary disease from the history or physical examination. As
examples:

● In a meta-analysis including 21 studies of routine chest radiography,

among a total of 14,390 routine chest radiographs, there were 1444
abnormal studies [99]. Only 140 abnormal findings were unexpected, and
only 14 (0.1 percent) of all routine chest radiographs influenced
management.

● In one retrospective study, 905 surgical admissions were evaluated for

the presence of clinical factors believed to be risk factors for an abnormal
preoperative chest radiograph [100]. The risk factors determined by the
investigators included age over 60 years or clinical findings consistent
with cardiac or pulmonary disease. No risk factors were identified in 368
patients; of these, only one (0.3 percent) had an abnormal chest
radiograph, which did not affect the surgery. Conversely, 504 patients
had identifiable risk factors; of these, 114 (22 percent) had significant
abnormalities on preoperative chest radiograph. No subgroup analyses
are available for review, but the authors note that older age was not
associated with increased risk of abnormal chest radiography in the
absence of other risk factors.

We do not suggest routine preoperative chest radiography for patients with

class III obesity (ie, BMI ≥40 kg/m2), unless additional criteria such as poor
exercise tolerance or unexplained dyspnea are present. Although routine
preoperative chest radiography is suggested by the American Heart
Association for patients with class III obesity [93], the relationship between
chest radiograph findings and perioperative morbidity are not well defined in
this population, and studies are not available to indicate that preoperative
radiographic abnormalities affect perioperative outcomes.

PULMONARY FUNCTION TESTS

Routine pulmonary function tests are not indicated for healthy patients prior
to nonpulmonary surgery. (See "Evaluation of perioperative pulmonary risk".)

These tests generally should be reserved for patients who have dyspnea,
poor exercise tolerance, or cough that remains unexplained after careful
clinical evaluation, particularly in the presence of risk factors for
postoperative pulmonary complications. Clinical findings are more predictive
of the risk of postoperative pulmonary complications than are spirometric
results [101]. These findings include decreased breath sounds, prolonged
expiratory phase, rales, rhonchi, or wheezes. The role of preoperative
pulmonary function tests is reviewed in detail elsewhere. (See "Evaluation of
perioperative pulmonary risk", section on 'Pulmonary function testing'.)

RECOMMENDATIONS OF OTHERS
● American Society of Anesthesiologists – The American Society of
Anesthesiologists (ASA) updated their practice advisory on pre-anesthesia
evaluation in 2012 [46]. The ASA does not recommend routine
preoperative testing. Selective testing may be indicated based on
information from the history and physical examination, or because of the
type or invasiveness of the planned procedure and anesthesia. The
advisory provides specific recommendations for each potential
preoperative test.
 ● Agency for Healthcare Research and Quality – The Agency for Healthcare
Research and Quality (AHRQ) found insufficient evidence for preoperative
testing before surgery [102].

● Health Technology Assessment Program (United Kingdom) – Limited

evidence indicated no benefit of complete blood count, electrolyte, and
renal function testing [103]. Among apparently healthy patients
undergoing surgery, abnormal results were uncommon, and only a small
proportion of these results changed perioperative management.

● National Institute for Health and Care Excellence (United Kingdom) – The
National Institute for Health and Care Excellence (NICE) guideline makes
specific recommendations on the selective use of each commonly
performed preoperative test [104]. The recommendations are stratified
based on ASA physical status classification and type of surgery (minor,
intermediate, major/complex). The guideline does not recommend
preoperative chest radiographs, urinalysis, or A1c screening. They
recommend selective testing.

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".)

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 education: Questions to ask if you are having
surgery or a procedure (The Basics)")

SUMMARY AND RECOMMENDATIONS

● Preoperative clinical evaluation – The overall risk of surgery is low in
healthy individuals, and the ability to stratify risk with commonly
performed evaluations is limited. Screening questionnaires can be helpful
in the preoperative evaluation, particularly to evaluate exercise capacity
(table 2). Important potential risk factors to discuss with the patient
include functional capacity, alcohol use, smoking, illicit drug use, and
medications. 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 testing is not indicated for most

patients – Routine preoperative laboratory tests have not been shown to
improve patient outcomes among healthy patients undergoing surgery.
We do not suggest routinely testing for serum electrolytes, blood
glucose, liver function, hemostasis, or urinalysis in the healthy
preoperative patient. Routine laboratory testing in healthy patients has
poor predictive value, potentially 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 and 'Laboratory
studies' above.)

• Preoperative hemoglobin measurement in select patients – We

suggest preoperative hemoglobin measurement in the following
circumstances (see 'Complete blood count' above):

- All patients ≥65 years of age undergoing major surgery

- Any patient undergoing surgery that is expected to result in
significant blood loss
- Any patient undergoing surgery (including minor surgery) if the
clinical history suggests severe anemia or worsening of chronic,
stable anemia

• Preoperative serum creatinine in select patients – In the revised

cardiac risk index (table 8), a serum creatinine >2.0 mg/dL predicted
postoperative cardiac complications. We suggest obtaining a serum
creatinine concentration in the following circumstances (see 'Kidney
function' above):

- Patients >50 years old undergoing intermediate- or high-risk

surgery
- Any patient suspected of having kidney disease
- If hypotension is likely during surgery
- If nephrotoxic medications will be used
 • Preoperative electrolytes in select patients – We do not routinely
check preoperative electrolytes unless there is a clinical history that
increases the likelihood of an abnormality, such as patients who take
diuretics, angiotensin-converting enzyme (ACE) inhibitors, or
angiotensin receptor blockers (ARBs). (See 'Electrolytes' above.)

• Preoperative pregnancy testing – We suggest preoperative

pregnancy testing in all females of reproductive potential rather than
use of history-taking alone to determine the potential for pregnancy.
(See 'Pregnancy testing' above.)

• Preoperative COVID-19 testing – We recommend polymerase chain

reaction (PCR) testing for severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) within 72 hours of elective surgery for all
asymptomatic patients regardless of vaccination status. (See 'COVID-19
screening and testing' above.)

● ECG is not indicated for asymptomatic patients undergoing low-risk

surgery – We suggest not ordering an electrocardiogram (ECG) for
asymptomatic patients undergoing low-risk surgical procedures, even for
patients with known cardiovascular disease.

According to the 2014 American College of Cardiology/American Heart

Association (ACC/AHA) guidelines, a resting 12-lead ECG should be part of
the preoperative evaluation in patients with known coronary artery
disease, significant arrhythmia, peripheral arterial disease,
cerebrovascular disease, or other significant structural heart disease
undergoing any other than low-risk surgical procedures.

A preoperative resting ECG can also 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".)

● Preoperative chest radiography is not indicated in the absence of

active, symptomatic cardiopulmonary disease – We suggest not
obtaining routine preoperative chest radiographs in healthy adults, even
before high-risk noncardiothoracic surgery, in the absence of active
cardiopulmonary disease (eg, a change in baseline symptoms in patients
with established cardiopulmonary disease) or symptoms (algorithm 2).
There is little evidence to suggest that preoperative chest radiographs
alter management or affect surgical outcomes unless there is known or
suspected active cardiopulmonary disease. (See 'Chest radiographs'
above.)
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