CHAPTER

Preoperative preparation
of the surgical patient

Jerry Stonemetz, MD 1, John C. Evanko, MD MBA 2

9
1
Medical Director, Perioperative Services, Anesthesia & Critical Care Medicine, Johns Hopkins
University, Baltimore, MD, United States; 2Executive Vice President & Chief Medical Officer,
MCIC Vermont, LLC, New York, NY, United States

Preparation of the surgical patient begins with a consideration of all phases of sur-
gical care when preparing a patient for surgery. Classic preoperative, intraoperative,
and postoperative phases should be on the mind of the surgeon when developing
their recommended surgical therapy. Initial presentation of the patient often reveals
considerable information about the physical and mental state of the patient and
should help guide the surgeon in recommending the most appropriate therapy to
achieve the desired therapeutic goal. Shared decision-making models should take
into account concerns about the intraoperative and postoperative phases of care
when a surgeon and patient decide upon the surgical options and desired treatment
goals during the preoperative phase.
The preoperative phase should be considered as two distinct phases, each with a
different goal and thought process. The surgical planning phase begins with the diag-
nostic workup, followed by the identification of pathology and the exploration of
treatment options. During this phase, the surgeon and patient are engaged in
continual dialogue about the patient’s goals, the various treatment options, and their
respective risks, benefits, and likelihood of successful treatment. Options of expec-
tant management, medical, alternative, and surgical treatments, to name a few,
should be explored with the patient. The patient’s pathology, state of health, and
comorbidities must be carefully considered and weighed against the considered
treatments and resulting recovery period. If surgical intervention is necessary,
open, minimally invasive, endoscopic, or endovascular surgical options should be
weighed against overall procedure length, anesthesia considerations, and immediate
postoperative care requirements. This entire process is considered shared decision-
making and results in the informed consent of a patient when a treatment option is
agreed upon.
The second phase of preoperative preparation begins once a recommended sur-
gery is deemed necessary and agreed to by the patient. This phase includes the med-
ical optimization and anesthesia evaluation of the patient undergoing the intended
procedure and the subsequent interpretation and evaluation of appropriate preoper-
ative testing deemed necessary. In a relatively healthy patient undergoing a minor
low-risk procedure, the preparation or testing can be kept to a minimum and will

Handbook of Perioperative and Procedural Patient Safety. https://doi.org/10.1016/B978-0-323-66179-9.00013-0 103

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104 CHAPTER 9 Preoperative preparation of the surgical patient

be discussed later in this chapter. A patient with a more complex medical history un-
dergoing a difficult and lengthy procedure with a significant anticipated recovery
period may require medical optimization in order to stabilize their medical condition
and enhance their physical condition prior to surgery. Complex medical conditions
out of the scope of the surgeon’s practice may necessitate consultations with various
medical specialties to manage their conditions preoperatively and postoperatively.
An evaluation of the patient’s social habits may indicate a need for referral to appro-
priate counseling to enhance the recuperation period and overall compliance with
medical recommendations. The patient’s family and support resources should be
evaluated to ensure adherence with postoperative restrictions and not place the pa-
tient in jeopardy during their anticipated recovery period. The results of these eval-
uations and considerations must be continually balanced against the original surgical
recommendation, and when necessary, the surgeon should recommend altering the
surgical plan to accommodate these realities in order to most safely achieve the
goal of treatment. After all, the dictum, primum non nocere, compels us to do no
harm and compels us to improve and not worsen the overall condition of the patient
with our surgical therapy.
Preoperative preparation can be very complex and often the care coordination
required to safely prepare a patient overwhelms the surgeon and their staff. The
number of consultations and referrals can multiply very quickly and the resulting
number of follow-up recommendations and options can confuse even the most expe-
rienced surgeon. Each of these interactions presents an opportunity for error, and
lack of coordination and preparation which may contribute to potential patient
harm and poor outcomes. Many healthcare systems and surgical programs are
employing multidisciplinary surgical care conferences to discuss upcoming complex
surgical cases in order to streamline the process and enhance teamwork among the
various disciplines of medicine. Effective conferences will include surgeons, anes-
thesiologists, internists, hospitalists, physiatrists, consultants, nurses, social workers,
care coordinators, patient navigators, and home care specialists in the discussion of
complex cases to ensure a tailored, comprehensive, and coordinated care plan is
developed addressing the needs of the patient. Risk calculators and other algorithms
may be employed to risk stratify appropriate candidates to be reviewed at the con-
ference if an institution decides not to review every case. Alternative treatment op-
tions and experienced opinions are often discussed culminating in the sharing of best
practices to be followed and the potential surgical pitfalls to be avoided. Necessary
hospital resources can be anticipated and properly resourced when discussed prior to
the surgery. Anesthesia concerns could be discussed with the appropriate consultants
to better understand the patient’s physiology and medical condition to guide intra-
operative monitoring and postoperative critical care needs. Medical comanagement
can be arranged for immediate postoperative hospitalization to aid the surgeon and
critical care teams in the medical management of the patient. Discharge planning
and home care coordination can be arranged with a better understanding of the antic-
ipated recovery status and limitations of the patient. The multidisciplinary confer-
ence enhances the preparation and coordination for all five phases of the surgical
 Preoperative preparation of the surgical patient 105

continuum: surgical planning, medical optimization, intraoperative, postoperative

hospitalization, and posthospital recovery phase. Care pathways and standardized
treatment protocols can easily be constructed and followed to improve care and
decrease variability and overall cost when a mature multidisciplinary conference
is established in the culture of an organization.
From the moment the patient and surgeon decide to proceed with surgery, the
preoperative time frame represents a golden opportunity to proactively manage
and optimize the patient for the upcoming surgery. These interventions include iden-
tification and prophylaxis of patients at risk for deep venous thrombosis and pulmo-
nary embolism; preoperative administration of beta-blockers; appropriate selection
of antibiotics; and better glycemic control of diabetic patients. We believe that the
future of perioperative medicine will usher in advances in proactively reaching
out to surgical patients during this preoperative time period and delivering
disease-specific management. There exists today technology that utilizes patient
health records and online questionnaires that are tied to decision support systems
to guide preoperative testing. By correctly identifying and risk stratifying surgical
patients, we can tailor clinical pathways that optimize their medical conditions as
well as better prepare them for surgery.
These authors are proponents of the preoperative clinic based on our experience
at our institutions as well as a plethora of published studies demonstrating
enhanced patient safety, patient satisfaction, reduction of testing and expenses,
as well as a significant reduction in cancellations and delays on the day of surgery.1
We work together for our collective institutions in improving the Preoperative Pro-
cesses, in an attempt to reduce malpractice claims and improve care. Our experi-
ence indicates that there are ample opportunities to reduce harm through better
organization and preoperative preparation. Our patients who are “optimized”
demonstrated fewer same-day cancellations, fewer day-of-surgery testing, and
lower PSI-90 Complication rates. Time will indicate if this process also results
in fewer malpractice claims.
However, not all patients should be required to make a separate trip to the hos-
pital for an evaluation prior to surgery. At our institutions, we have created a Preop-
erative Roadmap that has been provided to our surgeons to give some guidance as to
which patients should be selected to come to our clinic. Additionally, this roadmap
provides some basic algorithms that indicate what testing should be done on patients
deemed appropriate to bypass the clinic. This roadmap was developed based on prin-
ciples defined by the American Society of Anesthesiologists (ASA) Task Force on
Preoperative Testing convened in 2002 and updated based on new evidence
regarding specific patient conditions.1 Fig. 9.1 is a diagram of the algorithm we uti-
lize in our Roadmap to illustrate how to triage the surgical patient. Essentially, we
ask our surgeons to determine if their patients are medically “sick”or “healthy.”
Healthy patients only need to be seen in a preoperative clinic if they are having ma-
jor surgery. We define major surgery as specified by the American Heart Association
(AHA) as involving major blood vessels (vascular or cardiac) or extensive disruption
of physiology such as an 8-hour Whipple procedure or major transplant procedure.
106 CHAPTER 9 Preoperative preparation of the surgical patient

FIGURE 9.1
Preoperative triage algorithm. Low-risk medical conditions: Healthy with no medical
problems (ASA I) or well-controlled chronic conditions (ASA II). High-risk medical
conditions: Multiple medical comorbidities not well controlled (ASA III) or extremely
compromised function secondary to comorbidities (ASA IV). Low-risk surgical procedure:
Poses minimal physiological stress (e.g., minor outpatient surgery). Intermediate-risk
surgical procedure: Medium-risk procedure with moderate physiological stress and
minimal blood loss, fluid shifts, or postoperative changes. High-risk surgical procedure:
High-risk procedure with significant fluid shifts, possible blood loss, as well as
perioperative stress anticipated.
PEC, preoperative evaluation clinic; PMD, primary medical doctor. AdMay have
preanesthesia assessment done day of surgery. BdRecommend preanesthesia
assessment with PEC visit at least 24 h preoperatively. Should have an evaluation done
prior to PEC visit by PMD. CdRecommend preanesthesia consult scheduled in PEC at
least 48 h preoperatively. Should have an evaluation done prior to anesthesia consult by
PMD.
From Johns Hopkins Preoperative Roadmap, available at http://www.hopkinsmedicine.org/anesthesiology/
Patient_Care/Preoperative_Roadmap.pdf.
 Comorbidities 107

For a healthy patient scheduled for minor surgery, there really are no indica-
tions for much preoperative testing. Routine CxR and ECG are not warranted
for most patients. It is common to find a requirement for an ECG for all patients
over the age of 50; however, that is based on local custom and there is no real
good evidence that this should be required.2 Additionally, laboratory testing should
also be considered only for patient conditions or surgery that warrants the appro-
priate test. Minor outpatient surgery really only requires a hemoglobin level on
menstruating females and possibly a urine pregnancy test, unless there is some-
thing in the history that stipulates further testing is indicated. A good example
of a significantly oversubscribed preoperative test is coagulation studies.3 At
most institutions, a Prothrombin time (PT/INR) and Partial Thromboplastin tests
(PTTs) are ordered on the vast majority of patients. There are several problems
with ordering this test preoperatively. First, most labs have now split out the PT/
INR from the PTT, and ordering a PTT adds an additional cost to the test. There
are practically no preoperative patients that warrant a PTT. Exceptions are hemo-
philias, and these should be identified from a basic history and physical. The PTT
test represents the intrinsic coagulation pathway and is routinely used to monitor
heparin dosing. Obviously, preoperative patients are rarely on heparin, so this
test is worthless to obtain. As for the PT/INR, there are patients where this test
is indicated. They would be patients with a history of liver disease or bruising
and prolonged bleeding. Ironically, we typically order a PT/INR on patients on an-
ticoagulants such as Coumadin. Again, there is little rationale for ordering this test
preoperatively. These patients will all have abnormal values for their INR. There is
rationale for ordering the tests the morning of surgery, but not a few days prior to
surgery. Both of these examples illustrate how we can reduce the significant
expense of unnecessary preoperative testing without affecting outcomes.

Comorbidities
The roadmap also defines how to approach certain patient comorbidities as far as
appropriate testing (Table 9.1). Of particular concern is the patient who is not
able to achieve at least four metabolic equivalents (METs) of activity which is
defined as being able to climb two flights of stairs without stopping or walking
briskly for up to four city blocks. There are many reasons patients are not able to
achieve this level of activity, such as arthritis or obesity, but without attaining this
level of activity, we are not able to assess cardiac reserve. Consequently, we
frequently will want a cardiac ECHO for these patients, in particular, if they are
scheduled for intermediate or major surgery.4
The patient that represents one of our greatest challenges is the patient who is
morbidly obese as defined by a body mass index (BMI) > 40. These patients are
particularly prone to comorbidities that may seem unusual at an early age. The
most concerning combination of comorbidities are the presence of morbid obesity
and sleep apnea. This common combination may result in pulmonary hypertension
108 CHAPTER 9 Preoperative preparation of the surgical patient

Table 9.1 Medical conditions that may warrant an ASA III or IV status and
would benefit from a preoperative assessment at a PEC center.
General • Medical condition inhibiting ability to engage in normal daily
conditions: activitydunable to climb two flights of stairs without stopping.
• Medical condition necessitating continual assistance or
monitoring at home within the past 6 months.
• Admission to a hospital within the past 2 months for acute or
exacerbation of a chronic condition.
• History of previous anesthesia complications or history of
malignant hyperthermia.
Cardiocirculatory: • History of angina, coronary artery disease, or myocardial
infarction.
• Symptomatic arrhythmias, particularly new onset A-fib.
• Poorly controlled hypertension (systolic >160 and/or diastolic
>110).
• History of congestive heart failure.
• History of significant valvular disease (aortic stenosis, mitral
regurgitation, etc.).
Respiratory: • Asthma/COPD requiring chronic medication or with acute
exacerbation and progression within the past 6 months.
• History of major airway surgery or unusual airway anatomy
(history of difficult intubation in the previous anesthetic).
• Upper or lower airway tumor or obstruction.
• History of chronic respiratory distress requiring home ventilatory
assistance or monitoring.
Endocrine: • Insulin-dependent diabetes mellitus.
• Adrenal disorders.
• Active thyroid disease.
• Morbid obesity.
Neuromuscular: • History of seizure disorder or other significant CNS diseases
(multiple sclerosis, muscular dystrophy, etc.).
• History of myopathy or other muscular disorders.
Hepatic/renal/ • Any active hepatobiliary disease or compromise (hepatitis).
heme: • End-stage renal disease (dialysis).
• Severe anemias (sickle cell, aplastic, etc.).
From Johns Hopkins Preoperative Roadmap, available at http://anesthesiology.hopkinsmedicine.org/
wp-content/uploads/2018/10/Preoperative-Roadmap_10.9.18.pdf.

that is undiagnosed but may result in perioperative death if not recognized and dealt
with appropriately. These patients should have an ECHO to rule out pulmonary hy-
pertension, but unfortunately, these patients also have a body habitus that precludes
using the ECHO to assess right heart function. In this situation, the patient may need
a right heart catheterization.
 Medication management 109

Medication management
Historically, implicit in our orders for nothing per os (NPO) after midnight, we are
telling patients not to take their morning medications. Our thinking has changed
dramatically based on recent evidence. Now, we realize that most patients who
are on chronic medications really should continue those medications on the morning
of surgery, and through the perioperative period. There are exceptions, and they are
listed in Table 9.2. Specifically, we now realize that beta-blockers are important for

Table 9.2 Guidelines for preoperative medications.

As a general rule, for patients scheduled for surgery with anesthesia, we recommend all
medications should be continued on the day of surgery.

In particular, it is very important for patients to take their morning dosage of the
following medications:

• Beta-blockers and any antiarrhythmics such as Digoxin or Calcium Channel blockers.

• Asthmatic medications including inhalers, Theophylline, Singulair, and/or steroids.
• GERD medication.
• Statins such as Lipitor, Zocor, Crestor, etc.
• Aspirin e unless specifically told by their surgeon, patients should continue to take their
ASA if they have cardiac stents.
• ACE/ARBdconsider having patients take these if HTN is difficult to control without them.
• Consider starting patients on beta-blockers preoperatively who could be considered at
risk for cardiac ischemia.
Exceptions to this recommendation are summarized below:
Class of
medications Medication Recommendations

Oral Metformin/Glucophage Actos/ Hold at least 8 h preop.

hypoglycemic Glyburide/Tolinase/Avandia/ Recommend holding morning
agents Amaryl/all others dose, day of surgery.
Diuretics Lasix/HCTZ Hold morning day of surgery,
unless prescribed for CHFdthese
patients should take their morning
dose of diuretics.
ACE/ARB Lisinopril/Lotrel/Captopril/ Hold morning day of surgery,
Lotensin/Monopril/Prinzide/ unless prescribed for CHFdthese
Atacand/Benicar/Diovan/Avalide patients should take their morning
dose of meds.
Insulin NPH, regular Hold insulin morning day of
surgery. Bring insulin with patient
to hospital.
All herbal Stop all herbal supplements at
supplements least 24 h prior to surgery.
SGLT2 Canglifozin (Invokana)/ For all surgeries, stop 3 days prior
inhibitors Dapagliflozin (Farxiga)/ to surgery; for Ertuglifloxin, stop
Empaglifozin (Jardiance)/ 4 days prior to surgery.
Ertuglifloxin (Steglatro)
From Johns Hopkins Preoperative Roadmap, available at: https://anesthesiology.hopkinsmedicine.org/
wp-content/uploads/2022/08/FY23-Preoperative-Roadmap-7.22.pdf.
110 CHAPTER 9 Preoperative preparation of the surgical patient

improved surgical outcomes and, in fact, have become one of the SCIP measures.
This measure looks at whether a patient who is on a beta-blocker as a home medi-
cation has taken this medication within 24 h of surgery. Alternatively, a beta-blocker
can be administered intraoperatively, but the preferred recommendation is to have
the patient take their medicine orally preoperatively. This brings into question the
NPO status. We now feel that sips of water immediately prior to surgery are not a
problem, and there is some evidence to suggest that clear liquids taken within 2 h
of surgery may actually reduce postoperative nausea and vomiting. This recommen-
dation has taken on new light as it pertains to ERAS (Enhanced Recovery After Sur-
gery), which typically recommends up to 20 ounces of a carbohydrate drink, such as
Gatorade. It is the clear fluids and the carbohydrate loading that promotes a more
rapid return of bowel function.
Conversely, medications that are recommended to be held are listed below:
• Oral hypoglycemic agents: These should be held for at least 8 h preoperatively,
which means that patients who take them in the evening should be allowed to
continue these medications the night before surgery. One exception may be
Metformin for patients who are concomitantly going to receive contrast dye as
part of their procedure. These patients should have this medication stopped at
least 24 h prior to the procedure in an attempt to reduce the risk of renal failure.
The rationale for holding oral hypoglycemic comes from reports of profound
lactic acidosis in patients who received the medication preoperatively and were
undergoing major surgery. There have been no studies to date that look at the
consequences of taking these medications preoperatively in minor surgery;
however, we continue to recommend holding in light of a lack of evidence of
their safety.
• Insulin: Currently we recommend that all patients hold their morning dose of
short-acting insulin since they are not taking any oral glucose preoperatively.
Typically, we recommend they bring their morning insulin with them to the
hospital and once a blood sugar level is assessed, we can determine the
appropriate dosing of this medication. We also recommend that long-acting
agents such as Lantus be reduced by half the evening before surgery, although
we are not aware of any studies that demonstrate a problem with standard
dosing. We are seeing more patients taking long-acting insulin in the morning,
and we are recommending these patients take half of that dose prior to surgery.
Finally, we also try to counsel insulin diabetic patients that if they begin to feel
hypoglycemic preoperatively that they can take 8e10 ounces of clear apple
juice. Not orange juice or anything with pulpdjust clear apple juice. This
should not affect their ability to proceed with surgery.
• ACE Inhibitors/ARB: Today many patients are started on ACE inhibitors or
ARBs as the preferred therapy for hypertension. There are adequate studies to
illustrate that these patients have a high propensity to develop hypotension that
is unresponsive to normal pressors with the induction of general anesthesia. It
has been demonstrated that this hypotension is more responsive to vasopressin
 Medication management 111

presumably because this drug activates the rennindangiotensin pathway that is

suppressed by these inhibitors. Exceptions to this recommendation are those
patients who are prescribed these medications as therapy for congestive heart
failure. These patients should take their medications in the morning of the day
of surgery. Of note, there are some studies that have indicated that continuation
of these medications may have benefit as renal protection in patients undergoing
major vascular or cardiac surgery; however, the current recommendations are to
hold these medicines the morning of surgery.5
• Anticoagulants: Depending upon the specific anticoagulant prescribed and the
indications, stopping these drugs preoperatively will have variable time
frames.6 Typically, we recommend stopping Warfarin for 5 days and Clopi-
dogrel for 7 days preoperatively. Some patients will require anticoagulant
bridging with Lovenox which can be stopped 12e24 h preoperatively. One
aspect to consider is whether the patient is a reasonable candidate for regional
anesthesia rather than general anesthesia. For these patients, Warfarin must be
stopped for at least 5 days, Clopidogrel must be stopped for 7 days, and
Lovenox must be stopped for at least 24 h. Aspirin is not a contraindication to
regional anesthesia. Many surgeons want ASA stopped 7e10 days preop;
however, there is mounting evidence that we should reconsider this approach
except in a very few select types of surgery. The rationale for this recom-
mendation will be discussed below.
• Herbal medications: In general, since there is so little control over what con-
stitutes herbal medications, we generally recommend that these medicines be
stopped at least 24 h preoperatively.7 There are some specific supplements that
should be considered to be held even longer. Examples are fish oil and vitamin E
because of reported problems with bleeding, and most importantly any sup-
plements that contain ephedrada major ingredient in dietary supplements such
as Metabolife and Ma-Huang. This drug has been shown to cause cardiomy-
opathy similar to Fen-Phen which was taken off the market years ago.

Aspirin
Aspirin affects platelet function secondary to changes to platelets that occur during
their synthesis. Consequently, while on aspirin, a patient’s platelet function is
affected for the life of the platelets. Studies have demonstrated that for the vast ma-
jority of patients, essentially all antiplatelet activity will cease if aspirin is stopped
for 7 days. This also means that the platelets are primarily replaced within this time
frame as well. This explains the rationale for discontinuing aspirin 7 days prior to
surgery, despite the obvious benefits to patients who need this antiplatelet therapy.
Unfortunately, this current practice has now been shown to have absolute detri-
mental effects on a specific subset of patients, and that represents patients who
have cardiac stents in place.
The most recent recommendations from the AHA discuss patients who have had
stents placed recently, as well as patients who are past this initial critical window.8
112 CHAPTER 9 Preoperative preparation of the surgical patient

To summarize these recommendations, it is important to understand that patients

who have just had cardiac stents placed are at high risk of thrombosis of these stents,
and consequently that is why they are maintained on antiplatelet therapy. That ther-
apy is currently clopidogrel and aspirin. Essentially, patients who receive bare metal
stents should not have surgery unless life or limb-threatening for 6 months after
placement, and that is primarily because this dual antiplatelet therapy should not
be discontinued. For patients who receive drug-eluting stents, this dual therapy
should continue for at least 1 year. Obviously, any emergency surgery requires a
thorough discussion of benefits and risks between the patient, the surgeon, and typi-
cally their cardiologist.
Our major concern now, however, is the patient who is past this window of dual
antiplatelet therapy. The AHA does recommend life-long aspirin therapy in all of
these patients. Additionally, their recommendations are that aspirin is continued
up to the day of surgery except for neurosurgery and retinal surgery where the
risk of bleeding is so significant. Possibly even more important is the resumption
of antiplatelet therapy. Ideally, these patients should resume their medications the
day after surgery. For patients who are dual therapy, we do recommend stopping clo-
pidogrel 7 days prior to surgery but maintaining the 81 mg dosage of aspirin.
It is essential to understand some of the differences between clopidogrel and
aspirin in order to understand our recommendations. Clopidogrel affects platelet
function in a different manner than aspirin and is based on the circulating platelet
versus the synthesis of the platelet. As long as clopidogrel is in circulation, it will
negatively affect platelet function. Consequently, we cannot reverse this antiplatelet
activity by administering new platelets as we can with aspirin. That is why we
recommend stopping clopidogrel 7 days prior to surgery but continuing the low-
dose aspirin which seems to be an effective dosage to prevent thrombosis of these
stents. What we frequently see are cardiologists recommending stopping both
5 days prior to surgery in order to preserve some antiplatelet therapy. Our problem
with this approach is that it provides a scenario where we are unable to reverse the
antiplatelet activity by administering new platelets, whereas we can if they are sim-
ply on aspirin. It is also important to realize that in order to prevent stent thrombosis,
we need antiplatelet therapy, not anticoagulation. Hence, warfarin or heparin is not
an appropriate substitution.

Pacemakers
We are seeing an ever-increasing volume of patients with pacemakers inserted who
are now coming to surgery after the pacemaker has been implanted. One of the pri-
mary reasons for this increase is the rationale that patients with extremely low car-
diac function (ejection fractions of less than 30%) benefit substantially from
pacemaker insertions, and in general, these will be implantable cardioversion de-
vices (ICDs). It is important to understand how to manage these pacemakers preop-
eratively. The anesthesiologist will want documentation as to the type and function
of these pacemakers as well as a recent interrogation of this device.
 Conclusion 113

Our recommendations based on recent studies are that routine pacemakers need
interrogations within 6 months of surgery. Exceptions to this are pacer-dependent
patients and ICDs wherein both of these situations the pacemaker should have
been interrogated within 3 months of surgery.9
Additionally, it will be important to have a discussion with the anesthesiologist
as to the recommendation on how to handle the pacemaker during surgery. Their
concern will be the effect of electrocautery (Bovie) interference on the normal pace-
maker function. Essentially, a pacemaker will frequently sense such interference as
cardiac function, and the results will depend upon what type of pacemaker is
implanted. Routine pacemakers will likely sense Bovie interference as heartbeats
and suppress any discharges. This will be particularly problematic in the pacer-
dependent patient since this Bovie interference may result in no pacemaker
discharge causing asystole. An alternative method of dealing with pacer-
dependent patients will likely be to have the pacemaker reprogrammed into an asyn-
chronous mode which means there will be no sensing of the pacemaker. This results
in the constant firing of the pacemaker at the predetermined rate. Once the surgery is
completed, the pacemaker can be reprogrammed back to a sensing mode.
An ICD views Bovie interference differently. This device is looking for signs of
cardiac dysrhythmias such as ventricular fibrillation (VFib) or ventricular tachy-
cardia (VTach). After sensing one of these tachyarrhythmias, the ICD will attempt
cardioversion internally by emitting a shock. If it senses the Bovie instead and emits
this shock, the pacemaker may in fact generate VFib or VTach. Consequently, we
generally require the ICD function to be turned off prior to surgery and turned
back on once the case is completed.
There may be opportunities to place a magnet over the pacemaker or ICD to
accomplish these goals; however, without proper documentation of what will happen
with a magnet, it is not prudent to use the magnet since not all pacemakers function
the same with a magnet. This functionality should be defined in the interrogation
report. Additionally, the type of surgery may also preclude the use of a magnet
and consequently require reprogramming. We advise a discussion between the anes-
thesiologist and surgeon prior to surgery in order to avoid last-minute cancellations
or delays.

Conclusion
As the severity and acuity of medical problems increase in our surgical patients, it
will become ever more important to assess these patients prior to the day of surgery.
For hospitals that cannot afford a preoperative clinic, they must begin to explore
methods of proactively getting patient information so that rules-based logic can
be applied to their preoperative management. We feel online preoperative question-
naires represent great opportunities to better capture significant patient information
that is relevant to the appropriate triage for evaluations. For patients who are not able
to use the computer, the surgeon’s office staff can guide them through the
114 CHAPTER 9 Preoperative preparation of the surgical patient

questionnaire. This technology can significantly reduce cancellations and delays at

any institution.
Finally, we strongly recommend that the anesthesia department be engaged in
assisting to define these preoperative protocols and management since this informa-
tion is changing rapidly. We do not believe the typical surgeon should attempt to
remain current on the nuances of preoperative management and should come to
rely on their colleagues in anesthesia and other clinical specialties in a multidisci-
plinary manner to establish effective clinical guidance.

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