Preoperative Testing and Planning for Safer Surgery

Consensus statements and regulatory guidelines endorse the process of identifying patients at increased risk for surgical morbidity and mortality. This is termed prognostic testing, and it identifies patients who are deemed to be too sick to benefit from the anticipated gain of surgery. However, much more valuable than prognostic testing is predictive, or directive, testing. A predictive test pinpoints the patient’s problem that will benefit from a specific available intervention. This review covers what is risk?, changing paradigms of surgical success, building a case for moderation, so, does anyone disagree?, timing, frailty and age (and the eyeball test), is the heart the only organ that counts?, changing paradigms, the enhanced importance of functional capacity, resting electrocardiogram, exercise stress testing, ventricular function testing, stair climbing: putting it all together, pulmonary function tests, obstructive airway disease, perioperative nutrition, how can we make surgery safer?, enhanced recovery after surgery, putting it all together, extended enhanced recovery after surgery, tight glucose control, smoking cessation, and timing of collaboration with anesthesia. Figures show routine preoperative tests for elective surgery (adapted from the National Institute for Health and Care Excellence clinical guideline 3, preoperative assessment strategies and recommended risk-reducing therapy relative to American Society of Anesthesiologists (ASA) classification performed by the surgeon and age, ASA Class I and II patients may be safely be evaluated by an anesthesiologist on the day of their scheduled surgery for a full preoperative history and physical examination, flow volume loop. Tables list ASA physical status classification, effect of abnormal screening results on physician behavior, and minimum preoperative test requirements at the Mayo Clinic (in 1997).   This review contains 4 highly rendered figures, 3 tables, and 111 references