Perioperative & Surgical Care

Preoperative risk stratification and clearance

Clinical Overview and When to Suspect Elevated Perioperative Risk

— All patients undergoing intermediate- or high-risk surgery

— Patients with active cardiopulmonary symptoms (chest pain, dyspnea, syncope, palpitations)

— Known CAD, HF, valvular disease, arrhythmia, PAD, CVD, CKD, diabetes, OSA, cirrhosis

— Age >65 with frailty markers or polypharmacy

— Recent hospitalization, MI, stroke, or VTE

— Emergent (<6 h): Proceed; no time for testing — manage risk intraoperatively

— Urgent (6–24 h): Limited optimization; focused workup only

— Time-sensitive (1–6 weeks, e.g., oncologic): Balance delay risk vs optimization

— Elective: Full optimization allowed

— Low (<1%): Cataract, endoscopy, superficial, breast, ambulatory

— Intermediate (1–5%): Intraperitoneal, carotid, head/neck, orthopedic, urologic

— High (>5%): Aortic/major vascular, emergent major, prolonged with large fluid shifts

Step 3 management: When you see a preop consult question, your first three mental moves are (1) urgency of surgery, (2) surgical risk category, (3) patient's functional capacity in METs — these three filters determine whether any further testing is indicated. Skip this triage and you'll over-order stress tests on patients who don't need them.

Definition: Preoperative risk stratification estimates the probability of major adverse cardiac, pulmonary, renal, thromboembolic, and mortality events within 30 days of noncardiac surgery, and guides whether to proceed, optimize, or cancel.

"Clearance" is a misnomer — the consultant's role is risk estimation and medical optimization, not authorization. Documentation should read "patient is at X risk; recommendations include..." rather than "cleared for surgery."

Core question: Does the benefit of the planned surgery outweigh the patient-specific perioperative risk, given urgency, comorbidities, and functional status?

Who needs formal evaluation:

Surgical urgency tiers:

Surgical risk strata (30-day MACE):

Presentation Patterns and Key History

— Unstable coronary syndromes: MI within 60 days, unstable or severe angina (CCS III–IV)

— Decompensated HF (NYHA IV, new-onset, or worsening)

— Significant arrhythmias: high-grade AV block, symptomatic ventricular arrhythmia, SVT with HR >100, symptomatic bradycardia, new VT

— Severe valvular disease: severe AS (mean gradient >40, area <1.0), symptomatic MS

— <4 METs (poor): Can't climb a flight of stairs, walk up a hill, or do heavy housework → consider further testing if it changes management

— ≥4 METs (moderate–good): Can climb stairs, walk 4 mph, do yard work → usually proceed without further cardiac testing

— >10 METs (excellent): Strenuous sports → very low risk

Board pearl: If a patient cannot climb one flight of stairs without stopping, that alone reclassifies them as elevated risk — and DASI/METs-based history outperforms routine stress testing in low-to-intermediate risk surgery (METS-trial signal).

Setting: A patient is referred to your clinic 2–6 weeks before elective surgery, or you're consulted on an inpatient awaiting urgent/time-sensitive surgery. The stem will embed clues about cardiac, pulmonary, bleeding, or endocrine risk.

Cardiac history red flags ("active cardiac conditions" — pause and optimize first):

Functional capacity (METs) — single highest-yield history item:

Pulmonary: smoking pack-years, recent URI, OSA (STOP-BANG), home O₂, exercise tolerance, prior pulmonary complications

Bleeding/thrombosis: personal/family bleeding history, anticoagulants, antiplatelets, prior VTE, AFib, mechanical valves, recent stents (DAPT timing)

Endocrine/metabolic: diabetes control (HbA1c), steroid use >5 mg prednisone for >3 weeks, thyroid disease

Medication reconciliation: ACEi/ARB, diuretics, SGLT2 inhibitors, GLP-1 agonists, herbals, insulin regimen, opioids

Substance use: alcohol (withdrawal risk), tobacco, stimulants

Physical Exam Findings and Hemodynamic Assessment

— JVP elevation, S3, rales, peripheral edema → suggests decompensated HF; cancel/postpone elective surgery

— Crescendo–decrescendo systolic murmur at RUSB radiating to carotids with delayed upstroke → severe AS; needs echo and possibly intervention before elective high-risk surgery

— Irregularly irregular rhythm → AFib; rate control, anticoagulation strategy, TSH

— Carotid bruit: asymptomatic → no routine workup; symptomatic (TIA/stroke) → duplex

— Wheezing, prolonged expiration, accessory muscle use → optimize obstructive disease

— Decreased breath sounds, dullness → consider effusion or atelectasis

— Mallampati III–IV, thyromental distance <6 cm, limited neck extension, large neck circumference → difficult airway risk

— Timed Up-and-Go >12 sec, grip strength loss, gait speed <0.8 m/s, unintentional weight loss → frailty independently predicts mortality, delirium, and discharge to facility

Key distinction: A flow murmur in a young athlete decreases with Valsalva and is benign; the murmur of severe AS is harsh, late-peaking, and accompanied by a diminished or absent A2 and pulsus parvus et tardus — this finding alone mandates a preoperative TTE before intermediate/high-risk surgery, regardless of symptoms.

Vitals baseline: Document resting BP both arms, HR, RR, SpO₂ on room air, BMI, and orthostatics in elderly or symptomatic patients.

Cardiovascular exam — focused yield:

Pulmonary exam:

Airway assessment (anesthesia hands this off but you should note):

Frailty screen (≥65 yo):

Volume and perfusion: dry mucous membranes, capillary refill, skin turgor — especially in bowel-prep, dialysis, or diuretic patients

Surgical site exam: Look for active skin infection over planned incision — cellulitis or open wounds postpone clean elective procedures.

Diagnostic Workup — Initial Labs / Imaging / ECG / Biomarkers

— Indicated: Known CAD, significant arrhythmia, PAD, CVD, structural heart disease, or other significant cardiac risk factors undergoing intermediate/high-risk surgery

— Not indicated: Asymptomatic patients for low-risk surgery

— Compare with prior; new Q waves, LBBB, ischemic changes prompt further evaluation

— BNP/NT-proBNP: Reasonable in patients ≥65, or 45–64 with significant CV disease, undergoing elevated-risk noncardiac surgery (CCS guideline). Elevated BNP predicts MACE.

— High-sensitivity troponin: Useful for postoperative MINS surveillance, not routine preop screen.

Board pearl: "Routine preop CBC, BMP, coags, CXR, ECG in an asymptomatic healthy patient for cataract surgery" is a Choosing Wisely violation and a classic Step 3 wrong-answer trap — pick "no further testing."

Routine "preop labs" are NOT indicated in asymptomatic patients for low-risk surgery (Choosing Wisely). Order tests only to answer a clinical question raised by history or exam.

CBC: Indicated if anticipated significant blood loss, signs/symptoms of anemia, hematologic disease, or chemo/radiation history. Hgb <8 in elective major surgery → optimize first (iron, treat cause).

BMP/CMP: Indicated for known CKD, HTN on diuretics/ACEi, diabetes, liver disease, malnutrition, or major surgery with anticipated fluid shifts. Screen creatinine in patients ≥65 or undergoing nephrotoxic contrast.

Coagulation studies (PT/INR, aPTT): Only if bleeding history, liver disease, anticoagulation, or malnutrition — not routine.

Type & screen/crossmatch: Procedure-dependent.

Pregnancy test (β-hCG): Reasonable in reproductive-age women on day of surgery; required per many institutions. Document shared decision-making.

Glucose/HbA1c: Known or suspected diabetes; HbA1c >8% suggests poor control and elevated SSI risk; >8.5–9% prompts delay for elective surgery when feasible.

ECG:

CXR: Not routine; reserve for new/unstable cardiopulmonary symptoms or known significant disease.

Biomarkers:

Diagnostic Workup — Advanced or Confirmatory Studies

— Indicated for dyspnea of unknown origin, known/suspected HF with worsening symptoms, suspected significant valvular disease (any new murmur with symptoms or known severe disease without echo in past year)

— Not for routine LV function screening before noncardiac surgery

— Consider only if (1) elevated risk by RCRI or NSQIP AND (2) poor or unknown functional capacity (<4 METs) AND (3) results would change management (e.g., trigger revascularization or cancel surgery)

— Default modality: pharmacologic stress (dobutamine echo or vasodilator nuclear) if patient can't exercise

— Do NOT order stress testing for low-risk surgery or in patients with adequate functional capacity

— Indications mirror nonoperative ACS guidelines: unstable angina, NSTEMI/STEMI, high-risk stress test findings

— Preop revascularization for stable CAD does NOT reduce perioperative MI/death (CARP trial) — avoid prophylactic PCI just to "clear" for surgery

— Not routine; reserve for unexplained dyspnea, suspected undiagnosed obstructive disease, or before lung resection

— For lung resection: FEV1 and DLCO predict postop pulmonary complications; predicted postop values <40% raise concern

Step 3 management: The stress test question algorithm — "elevated risk + poor functional capacity + management will change" must all be yes. If any is no, the answer is "proceed to surgery without further testing."

Resting TTE:

Stress testing (pharmacologic or exercise):

Coronary angiography:

Pulmonary function tests:

Sleep study: STOP-BANG ≥3 with planned major surgery or known OSA without recent eval; impacts postop monitoring and CPAP planning.

Carotid duplex: Only in symptomatic patients; do not screen asymptomatic bruits.

Frailty/CPET: Cardiopulmonary exercise testing (anaerobic threshold <11 mL/kg/min predicts complications) is useful in major abdominal/thoracic surgery centers.

Risk Stratification — RCRI, NSQIP, and Integrated Algorithm

— High-risk surgery (suprainguinal vascular, intraperitoneal, intrathoracic)

— Ischemic heart disease

— History of CHF

— History of cerebrovascular disease

— Insulin-treated diabetes

— Preoperative creatinine >2.0 mg/dL

— Step 1: Emergency? → proceed, manage risk perioperatively

— Step 2: Active/unstable cardiac condition (recent MI <60 d, decompensated HF, severe valvular dz, significant arrhythmia)? → optimize before elective surgery

— Step 3: Low-risk surgery (MACE <1%)? → proceed

— Step 4: Estimate functional capacity. ≥4 METs without symptoms → proceed

— Step 5: <4 METs or unknown + elevated RCRI/NSQIP risk → consider further testing only if it will change management; otherwise proceed

Board pearl: Memorize the six RCRI predictors cold — every Step 3 preop vignette can be scored in your head, and the score directly drives the next-step answer. Insulin-treated DM counts; diet-controlled does not. Creatinine cutoff is >2.0, not 1.5.

Revised Cardiac Risk Index (RCRI) — 6 predictors, each = 1 point:

RCRI MACE risk: 0 points ≈ 0.4%, 1 ≈ 1%, 2 ≈ 2.4%, ≥3 ≈ ≥5%

NSQIP MICA / Surgical Risk Calculator: Procedure-specific, web-based; integrates age, ASA class, functional status, creatinine, and surgery type — often outperforms RCRI in modern cohorts. Use for shared decision-making.

ACC/AHA stepwise algorithm:

ASA Physical Status (anesthesia): I (healthy) → V (moribund); ASA ≥III correlates with higher complication rates.

Frailty integration: In ≥65 yo, frailty (Clinical Frailty Scale ≥5) independently predicts mortality and should trigger geriatrics consult, prehab, and goals-of-care discussion.

Pharmacotherapy — Perioperative Medication Management

— Beta-blockers: Never stop abruptly; rebound ischemia/tachycardia. Continue chronic therapy.

— Statins: Continue and initiate in vascular surgery patients — reduces MACE.

— Aspirin: Continue if secondary prevention with stents (per cardiology); for primary prevention, hold 7 days before major surgery.

— Inhaled bronchodilators, antiepileptics, antiparkinsonians, antipsychotics, SSRIs, thyroid hormone

— ACEi/ARB: Hold morning of surgery — reduces intraoperative hypotension (especially with general anesthesia and significant fluid shifts)

— Diuretics: Hold morning of surgery

— Oral hypoglycemics: Hold morning of surgery

— SGLT2 inhibitors: Stop 3–4 days before surgery (euglycemic DKA risk)

— GLP-1 agonists: Hold day of surgery (daily) or 1 week (weekly) — aspiration risk from delayed gastric emptying

— NSAIDs: Hold 3 days before (renal/bleeding)

— Herbals: Stop 1 week before (garlic, ginkgo, ginseng → bleeding; ephedra → hemodynamic)

Step 3 management: SGLT2 inhibitor → stop 3–4 days preop; this is a newer, high-yield answer choice replacing older "continue all medications" traps.

Continue these on day of surgery:

Hold on day of surgery (typically):

Insulin: Long-acting basal ≈ 50–80% of usual dose night before/morning of; hold short-acting prandial while NPO; resume sliding scale.

Beta-blocker initiation: Do NOT start beta-blockers on day of surgery in beta-blocker-naïve patients (POISE trial — increased stroke and mortality). If indicated, start ≥2–7 days preop and titrate.

Chronic steroids (>5 mg prednisone >3 weeks within past year): Stress-dose hydrocortisone for major surgery (e.g., 50–100 mg IV induction); minor procedures usually need only home dose.

Antibiotic prophylaxis (SCIP): Cefazolin within 60 min of incision; vancomycin within 120 min; redose for prolonged cases or large blood loss.

Anticoagulation Bridging, Antiplatelet Timing, and DAPT After Stents

— Stop 5 days preop; check INR day before — if >1.5, give vitamin K 1–2 mg PO

— Bridge with LMWH only if high thromboembolic risk: mechanical mitral valve, any mechanical valve + risk factors, recent (<3 mo) VTE, CHA₂DS₂-VASc ≥7, or recent stroke (BRIDGE trial: no bridge for most AFib patients)

— Resume warfarin 12–24 h postop if hemostasis adequate

— Low bleeding risk surgery: stop 24 h before

— High bleeding risk surgery: stop 48 h (longer for dabigatran with CKD)

— No bridging needed — short half-life

— Resume 24 h (low risk) or 48–72 h (high risk) postop

— Bare-metal stent: delay elective surgery ≥30 days

— Drug-eluting stent: delay ≥6 months (ideally 12 mo); ≥3 mo may be acceptable for time-sensitive surgery after shared decision-making with cardiology

— Continue aspirin throughout perioperative period whenever possible; hold P2Y12 inhibitor (clopidogrel 5 d, ticagrelor 3–5 d, prasugrel 7 d) for surgeries requiring it

— Low risk: early ambulation ± mechanical

— Moderate: mechanical + pharmacologic (LMWH or UFH)

— High (Caprini ≥5): LMWH + mechanical; consider extended prophylaxis (28 d) for major abdominal/pelvic cancer and orthopedic surgery

CCS pearl: If a stem describes elective hernia repair 2 months after DES placement, the correct CCS move is "postpone elective surgery" and continue DAPT — don't stop clopidogrel early to accommodate a non-urgent operation.

Warfarin:

DOACs (apixaban, rivaroxaban, dabigatran, edoxaban):

Antiplatelet therapy after coronary stents — delay elective surgery:

VTE prophylaxis (Caprini score):

Neuraxial anesthesia timing: LMWH prophylactic dose → 12 h before; therapeutic → 24 h; reverse warfarin first.

Special Populations — Elderly and Renal/Hepatic Impairment

— Cognition: Mini-Cog or MoCA at baseline — predicts postop delirium; abnormal screen → geriatrics consult

— Function: ADLs/IADLs, gait speed, falls history

— Frailty: Clinical Frailty Scale ≥5 → 2–3× mortality

— Polypharmacy: Beers criteria review; deprescribe anticholinergics, benzodiazepines, long-acting sulfonylureas

— Nutrition: albumin <3.0 or unintentional weight loss >10% in 6 mo → high complication risk; consider preop nutritional optimization

— Goals of care: Document advance directives, code status, surrogate decision-maker before surgery

— eGFR <60: ↑ risk of AKI, bleeding, MACE

— Avoid nephrotoxins (NSAIDs, aminoglycosides, IV contrast when possible)

— Dialysis patients: dialyze within 24 h before surgery; check K+ on morning of surgery (hold if >5.5); avoid IV fluid overload

— Dose-adjust antibiotics, LMWH (use UFH if CrCl <30), opioids (avoid morphine, meperidine → metabolite accumulation)

— Child-Pugh and MELD predict mortality: MELD <10 generally safe; 10–15 intermediate; >15 high; >20 prohibitive for elective surgery

— Manage coagulopathy with FFP/cryoprecipitate only if active bleeding or pre-procedural per TEG; routine INR correction is not indicated (rebalanced hemostasis)

— Manage ascites (paracentesis preop if tense), encephalopathy (lactulose, rifaximin), and avoid hepatotoxins

— Avoid acetaminophen >2 g/day, NSAIDs, and prolonged opioids

Board pearl: MELD >15 + elective abdominal surgery = recommend deferral or alternative; this is one of the most testable Step 3 cirrhosis surgical-risk thresholds.

Geriatric assessment (≥65 yo):

CKD:

Cirrhosis:

Postop delirium prevention: orient frequently, restore glasses/hearing aids, normalize sleep-wake cycle, minimize tethers (Foley, restraints), avoid benzodiazepines and anticholinergics, treat pain with scheduled non-opioid regimens.

Special Populations — Pregnancy, Pediatrics, and Other Subgroups

— Elective surgery: defer until after delivery

— Urgent/non-deferrable surgery: prefer second trimester (lower miscarriage/preterm labor risk than first; lower aortocaval compression than third)

— Left lateral tilt ≥15° after 20 weeks to avoid IVC compression

— Fetal monitoring: viable fetus (≥24 wks) → continuous intraop monitoring when feasible; OB consultation

— VTE prophylaxis: LMWH preferred (does not cross placenta); pregnancy is itself a hypercoagulable state

— Avoid NSAIDs after 20 weeks; minimize ionizing radiation; antibiotics safe in pregnancy include penicillins, cephalosporins, azithromycin

— Recent URI: defer elective surgery 2–4 weeks (laryngospasm/bronchospasm risk)

— NPO guidelines: clear liquids 2 h, breast milk 4 h, formula/light meal 6 h, fatty meal 8 h

— Routine labs not indicated in healthy children

— Family history of malignant hyperthermia → use non-triggering anesthesia (avoid succinylcholine, volatile agents)

— OSA screening (STOP-BANG), CPAP optimization

— Difficult airway preparation; positioning for ramped intubation

— VTE risk elevated — weight-based LMWH; mechanical prophylaxis

— Glycemic optimization; HbA1c <8% goal

Key distinction: Second-trimester surgery in pregnancy is the least risky window, not the first — a common reversal trap on the exam.

Pregnancy:

Pediatrics:

Obesity/bariatric:

Active cancer: Coordinate with oncology on chemo timing (avoid surgery during neutropenic nadir, typically 7–14 d post-cycle); recent bevacizumab → hold ≥4 weeks (wound healing); G-CSF if neutropenic.

Substance use: Alcohol withdrawal protocols, nicotine cessation (≥4–8 weeks preop reduces pulmonary/wound complications), buprenorphine continuation typically preferred over discontinuation for opioid use disorder.

Complications and Adverse Outcomes

— Perioperative MI/MINS (myocardial injury after noncardiac surgery): defined as troponin elevation within 30 days postop; often silent (no chest pain) — surveillance troponin in high-risk patients on POD 1–3 is reasonable

— Most periop MIs are type 2 (demand ischemia from tachycardia, anemia, hypotension) — treat the trigger, not just antithrombotics

— New AFib, decompensated HF, hypertensive urgency

— Atelectasis, pneumonia, respiratory failure, prolonged intubation

— Risk factors: age >60, COPD, smoking, OSA, upper abdominal/thoracic surgery, prolonged operation

— Prevention: incentive spirometry, early ambulation, lung-protective ventilation, regional anesthesia where possible, CPAP for OSA

— AKI: pre-renal (hypovolemia), intrinsic (contrast, nephrotoxins, hypotension), post-renal (Foley issues, retention)

— Monitor I/O, daily creatinine in high-risk patients

— Surgical site infection: prevention bundle (chlorhexidine bath, hair clipping not shaving, normothermia, glucose <180, timely antibiotics)

— CAUTI, CLABSI, pneumonia

Step 3 management: Postop POD 2 patient with troponin bump and no chest pain → diagnose MINS, evaluate for type 1 vs type 2, start aspirin + statin, treat reversible triggers (anemia, hypotension, tachycardia); cardiology consult.

Cardiac:

Pulmonary:

Renal:

Thromboembolic: DVT, PE — particularly in orthopedic, oncologic, and prolonged immobilization cases

Bleeding: Surgical site, GI stress ulcer (PPI/H2 in mechanically ventilated, coagulopathic, or high-dose steroid patients), retroperitoneal

Infectious:

Neurologic: Postop delirium (15–50% in elderly), stroke (rare, higher in vascular/cardiac surgery)

Endocrine: Hyper/hypoglycemia, adrenal crisis (missed stress-dose steroids), thyroid storm in untreated hyperthyroid

When to Escalate Care — ICU, Consult, or Inpatient Triage

— Active ischemic symptoms or recent ACS

— Decompensated HF or new-onset HF

— Severe valvular disease (severe AS, severe MR/MS, symptomatic AR)

— Significant arrhythmia: high-grade AV block, sustained VT, AFib with RVR

— Adult congenital heart disease undergoing intermediate/high-risk surgery

— Recent coronary stent within DAPT-mandatory window

— Major vascular (AAA, carotid), cardiothoracic, intracranial

— High blood loss anticipated or occurred

— Hemodynamic instability, vasopressor need

— Severe comorbid disease (EF <30%, severe pulmonary HTN)

— Delayed extubation, anticipated airway concerns

CCS pearl: Pheochromocytoma stem before adrenalectomy — the correct sequence is alpha-blockade (phenoxybenzamine) for 10–14 days first, then add beta-blocker only after alpha is established. Reversing this order can precipitate hypertensive crisis — a classic CCS trap.

Cardiology consultation indicated:

Pulmonology: Severe COPD/asthma with frequent exacerbations, home O₂, pulmonary hypertension, suspected undiagnosed restrictive disease before major surgery.

Hematology: Known bleeding disorder, unexplained coagulopathy, heparin-induced thrombocytopenia history, complex anticoagulation decisions.

Endocrinology: Poorly controlled diabetes (HbA1c >9%), pheochromocytoma (requires alpha- then beta-blockade before surgery), Cushing/Addison, thyroid storm risk, insulin pump management.

Nephrology: ESRD on dialysis, advanced CKD with electrolyte derangement, transplant patients (immunosuppression management).

Anesthesia preop clinic: Difficult airway, OSA, malignant hyperthermia history, complex comorbidity stacking, ASA III–IV.

Geriatrics/palliative care: Frailty, dementia, goals-of-care clarification, complex polypharmacy.

Planned ICU admission criteria postop:

Key Differentials — Same-Category Cardiac Risk Mimics

— Stable: predictable exertional pattern, no recent change → optimize medically, usually proceed

— Unstable: rest pain, crescendo pattern, new onset CCS III–IV → active cardiac condition, defer elective surgery, cardiology

— NSTEMI/STEMI within 60 days → defer elective surgery; delay 60 days minimum after MI per ACC/AHA, longer if revascularized with DES

— Compensated chronic HFrEF/HFpEF: continue GDMT, proceed with monitoring

— Decompensated (rales, JVD, S3, weight gain) → diurese, optimize, defer

— Severe AS (mean gradient ≥40 mmHg, AVA <1.0 cm², peak velocity ≥4 m/s): symptomatic → intervention (SAVR/TAVR) before elective intermediate/high-risk surgery; asymptomatic severe AS may proceed with careful hemodynamic management

— Severe MR/MS: evaluate for intervention before elective major surgery

— Prosthetic valves: anticoagulation bridging decisions; endocarditis prophylaxis per AHA

— Chronic stable AFib with rate control → proceed; manage anticoagulation

— New AFib with RVR → rate control, evaluate cause, defer elective surgery

— High-grade AV block → pacemaker before elective surgery

— Symptomatic bradycardia → evaluate

Key distinction: Asymptomatic severe AS is not an absolute contraindication, but symptomatic severe AS (angina, syncope, HF) mandates intervention first — the symptom triad changes the entire algorithm.

When a preop patient presents with chest discomfort, dyspnea, or abnormal ECG, distinguishing among cardiac etiologies determines whether surgery proceeds:

Stable angina vs unstable angina:

Acute coronary syndrome:

Heart failure:

Valvular disease:

Arrhythmias:

Pulmonary hypertension: severe (mPAP >55) → very high perioperative mortality; coordinate with PH center.

Key Differentials — Non-Cardiac Conditions Affecting Surgical Risk

— COPD exacerbation: wheezing, prolonged expiration, ↑ sputum → treat with bronchodilators ± steroids, defer elective surgery until at baseline

— Asthma: poorly controlled (recent ED visit, oral steroids) → optimize before elective surgery; peak flow at baseline

— Pulmonary embolism: acute dyspnea, tachycardia, hypoxia, unilateral leg swelling → CT-PA, anticoagulation, defer elective surgery 1–3 months

— OSA: undiagnosed → STOP-BANG screen; severe OSA increases postop respiratory failure and cardiac events

— Iron deficiency, B12/folate, CKD-related, chronic disease — workup and treat before elective surgery; IV iron 4–6 weeks preop for major surgery improves outcomes and reduces transfusion

— Preoperative Hgb <10 in major surgery = independent risk factor for mortality

— Untreated hyperthyroidism → thyroid storm risk; defer elective surgery, treat with methimazole + beta-blocker

— Severe hypothyroidism (myxedema) → defer; levothyroxine replacement

Board pearl: Preoperative IV iron for iron-deficiency anemia 4–6 weeks before major elective surgery is now a Step 3-testable optimization step — it reduces transfusion need and complications.

Pulmonary mimics of cardiac dyspnea:

Anemia:

Diabetes complications: poor wound healing, infection, autonomic neuropathy (silent ischemia, hemodynamic lability), gastroparesis (aspiration risk)

Thyroid disease:

Adrenal insufficiency: primary, secondary, or steroid-induced — stress-dose steroids for major surgery

Coagulopathy: liver disease, vitamin K deficiency, von Willebrand disease, hemophilia — hematology input, factor replacement plans

Infection: active bacteremia, untreated UTI before urologic instrumentation, cellulitis at surgical site, untreated dental abscess before joint replacement — treat before elective surgery

Malnutrition: albumin <3.0, prealbumin low, weight loss >10% — nutritional optimization 7–14 days improves outcomes in major surgery

Postoperative Plan, Secondary Prevention, and Discharge Medications

— Beta-blockers, statins, ACEi/ARB (once volume status and renal function stable), inhalers, antiepileptics — within 24–48 h

— Anticoagulants: per bleeding risk and surgical clearance; bridge plan if needed

— Antiplatelets after stents: resume aspirin POD 1 if hemostasis adequate; P2Y12 inhibitor per cardiology

— Insulin/oral hypoglycemics: resume with oral intake; transition off sliding scale to home regimen

— Standard surgery: until ambulatory or hospital discharge

— Extended (28–35 days): total hip/knee arthroplasty, major abdominal/pelvic cancer surgery

— Mechanical + pharmacologic combined for highest-risk patients

— Aspirin, high-intensity statin, beta-blocker, ACEi if reduced EF or HTN

— Outpatient cardiology follow-up within 1–2 weeks; stress imaging or angiography per type 1 vs 2 distinction

Step 3 management: Discharge after major vascular surgery → aspirin + high-intensity statin + ACEi/ARB if BP/EF appropriate + smoking cessation counseling — these four are the standard secondary prevention bundle and a frequent answer set.

Resume chronic medications systematically:

VTE prophylaxis duration:

Surgical site infection prevention continuation: wound care education, no submersion until cleared, watch for redness/drainage/fever

Cardiac secondary prevention if perioperative MI/MINS detected:

Pulmonary recovery: incentive spirometry, smoking cessation reinforcement (nicotine replacement, varenicline, bupropion), pulmonary rehab if applicable

Glycemic targets postop: 140–180 mg/dL inpatient (avoid <110); resume home regimen with appropriate adjustment if HbA1c was elevated — refer to PCP/endocrine within 2 weeks

Delirium/cognitive recovery: medication review, sleep hygiene, mobilization; consider postdischarge cognitive follow-up in elderly

Pain management: multimodal (acetaminophen scheduled, NSAIDs if appropriate, regional anesthesia, gabapentinoids); minimize opioid duration — provide naloxone, monitor for OUD

Follow-Up, Monitoring Parameters, and Rehab/Counseling

— Surgical wound check: POD 7–14 with operating surgeon

— PCP visit: within 1–2 weeks for medication reconciliation, comorbidity reassessment, lab follow-up

— Specialty follow-up: cardiology within 2–4 weeks if periop cardiac event; endocrine if glycemic dysregulation; pulmonology if respiratory complication

— Cardiac: BP log, daily weight if HF history, surveillance troponin if elevated risk on POD 1–3 (inpatient)

— Renal: BMP within 1 week if AKI risk, baseline CKD, or new diuretic/ACEi changes

— Glycemic: glucose log; HbA1c at 3 months if new insulin or regimen change

— Anticoagulation: INR 3–5 days after warfarin resumption; bridging plan documented

— Hemoglobin: repeat in 4–6 weeks if anemia or significant intraoperative loss; iron studies if persistent

— Cardiac rehab: referral within 2 weeks of MI, CABG, valve surgery, PCI — class I recommendation, underutilized

— Pulmonary rehab: for COPD with exacerbations, after major thoracic surgery

— Physical therapy: orthopedic surgery, deconditioned elderly, post-ICU

— Prehab (pre-surgery): emerging evidence — 4–6 weeks of structured exercise, nutrition optimization, smoking cessation improves outcomes

— Smoking cessation: every visit, offer pharmacotherapy + behavioral support

— Driving restrictions: vary by surgery (often 1–2 weeks for abdominal, longer for orthopedic, until off opioids)

— Return-to-work timeline

— Red flags warranting urgent return: fever >38.5, wound drainage, calf swelling, chest pain, dyspnea, syncope

Board pearl: Cardiac rehabilitation referral after periop MI is class I and significantly reduces mortality — yet underutilized; if a Step 3 stem asks "next step at discharge," cardiac rehab referral is often the right answer when offered.

Standard follow-up cadence:

Monitoring parameters:

Rehabilitation:

Counseling:

Ethical, Legal, and Patient Safety Considerations

— Capacity, disclosure of risks/benefits/alternatives, voluntariness, understanding

— Discuss procedure-specific risks (e.g., 1–5% MACE in intermediate-risk surgery for given patient), alternatives (including non-operative), expected recovery

— Special situation: emergency surgery in unconscious patient without surrogate → implied consent doctrine permits life-saving intervention

— Hierarchy varies by state but typically: spouse → adult children → parents → siblings

— Use substituted judgment (what would patient want) over best-interest standard when patient preferences are known

— Advance directives and POLST should be reviewed and documented preoperatively

— DNR orders are not automatically suspended — require explicit discussion and documentation

— Options: full suspension during anesthesia, procedure-directed limited resuscitation, or maintained DNR

— Document specifically which blood products are refused; advance directive ideally signed; discuss alternatives (cell salvage, EPO, IV iron, antifibrinolytics)

— Adult competent patient's refusal must be respected even if life-threatening

— Medication reconciliation at every handoff is the highest-yield error reduction step

— Use structured handoffs (SBAR, I-PASS) between preop clinic → OR → PACU → floor → discharge

— Postdischarge: ensure follow-up appointments scheduled before discharge, medication list reconciled with patient teach-back, written instructions, contact number for after-hours questions

Step 3 management: A patient with valid DNR scheduled for surgery requires an explicit preop conversation documenting whether DNR is suspended, modified (procedure-directed), or maintained intraoperatively — failure to do so is a patient-safety and ethical violation, not a default-suspend situation.

Informed consent essentials:

Surrogate decision-making:

DNR in the OR:

Jehovah's Witness patients:

Transition-of-care safety:

Never events: wrong-site/wrong-patient/wrong-procedure surgery → mandatory time-out with team verification per Universal Protocol; retained foreign body → mandatory counts

Mandatory reporting: elder/child abuse identified during preop history, certain infectious diseases, gunshot/stab wounds

High-Yield Associations and Rapid-Fire Clinical Facts

Board pearl: Master these 30 numbers and you'll answer 80% of preop vignettes on first read.

RCRI predictors (memorize): high-risk surgery, IHD, CHF, CVD, insulin-treated DM, Cr >2.0

METs threshold for stress test deferral: ≥4 METs

MI → elective surgery wait: ≥60 days minimum

BMS → elective surgery wait: ≥30 days on DAPT

DES → elective surgery wait: ≥6 months (ideally 12); ≥3 mo if time-sensitive

SGLT2 inhibitor hold: 3–4 days preop (euglycemic DKA)

GLP-1 agonist hold: daily forms 1 day; weekly forms 1 week (aspiration)

ACEi/ARB: hold morning of surgery

Statin in vascular surgery: start and continue — class I

Stress-dose steroids: if >5 mg prednisone for >3 weeks within past year and major surgery

HbA1c goal preop: <8% ideal; >9% consider deferring elective surgery

Glucose target intraop/postop: 140–180 mg/dL

Pheochromocytoma: alpha-block first (10–14 d), then beta-block

MELD >15: elective abdominal surgery high-risk; >20 prohibitive

OSA screen: STOP-BANG ≥3

Pregnancy elective surgery window: second trimester

Pediatric URI: defer elective 2–4 weeks

Smoking cessation benefit: ≥4–8 weeks preop reduces pulmonary complications

Iron deficiency anemia preop: IV iron 4–6 weeks before major surgery

Bridging anticoagulation: mechanical mitral valve, recent VTE (<3 mo), CHA₂DS₂-VASc ≥7

CARP trial takeaway: no prophylactic PCI before vascular surgery for stable CAD

POISE trial takeaway: don't start beta-blockers day of surgery in naïve patients

DASI questionnaire: structured METs estimation (METS trial)

Bevacizumab hold: ≥4 weeks preop (wound healing)

Carotid bruit: workup only if symptomatic

Severe AS triad: angina, syncope, HF

Choosing Wisely: no routine preop labs/ECG/CXR for low-risk surgery in asymptomatic patients

Caprini score ≥5: VTE prophylaxis with LMWH + mechanical

Frailty Scale ≥5: geriatrics consult, goals-of-care discussion

Board Question Stem Patterns

Key distinction: When in doubt between "test further" and "proceed," ask whether the test result would change management. If the patient would have surgery either way, skip the test.

Pattern 1 — "Cataract surgery in asymptomatic 68-year-old": Stem lists "ECG, CBC, BMP, CXR" as options. Answer: no preoperative testing indicated (Choosing Wisely).

Pattern 2 — "65-year-old with DM and HTN climbing 2 flights of stairs without symptoms, intermediate-risk surgery": Stem asks about stress testing. Answer: proceed without further testing (≥4 METs).

Pattern 3 — "Patient with DES placed 4 months ago needs elective hernia repair": Answer: postpone surgery until DAPT period complete.

Pattern 4 — "AFib patient on warfarin needs elective colonoscopy": CHA₂DS₂-VASc 3, no mechanical valve, no recent VTE. Answer: stop warfarin 5 days, no bridging (BRIDGE trial).

Pattern 5 — "Patient on dapagliflozin for type 2 DM scheduled for surgery in 2 days": Answer: hold SGLT2 inhibitor now (3–4 days preop) to prevent euglycemic DKA.

Pattern 6 — "60-year-old with crescendo–decrescendo murmur, exertional syncope, and pre-op TTE shows aortic valve area 0.8 cm²": Answer: delay elective surgery; refer for AVR (SAVR or TAVR) first.

Pattern 7 — "Patient with pheochromocytoma scheduled for adrenalectomy": Answer: start phenoxybenzamine for 10–14 days, then add beta-blocker.

Pattern 8 — "POD 2 patient with troponin elevation but no chest pain": Diagnosis: MINS; manage with aspirin, statin, address triggers (anemia/hypotension/tachycardia), cardiology consult.

Pattern 9 — "Pregnant woman at 26 weeks needs appendectomy": Answer: proceed (urgent); left lateral tilt, OB consult, fetal monitoring, prefer regional or careful general anesthesia.

Pattern 10 — "Elective major surgery in patient with HbA1c 10.5%": Answer: postpone, optimize glycemic control.

Pattern 11 — "Chronic prednisone 15 mg/day for 6 months, scheduled for major surgery": Answer: stress-dose hydrocortisone.

Pattern 12 — "MI 30 days ago, elective surgery scheduled": Answer: delay surgery to ≥60 days post-MI.

Pattern 13 — "Beta-blocker–naïve patient about to undergo vascular surgery tomorrow": Answer: do NOT start beta-blocker today; start statin instead.

One-Line Recap

Preoperative risk stratification is a structured, urgency-and-comorbidity-weighted estimation of perioperative morbidity and mortality that guides optimization rather than authorization — anchored by surgical risk category, functional capacity in METs, and validated calculators (RCRI/NSQIP) — with the consultant's job to medically optimize, not to "clear."

Triage trio first: urgency of surgery → surgical risk tier → functional capacity (METs). These three filters resolve most preop questions before any test is ordered.

Test only if it will change management: routine preop labs, ECG, and stress tests in asymptomatic patients for low-risk surgery are Choosing Wisely violations and Step 3 wrong-answer traps.

Medication management is high-yield: continue beta-blockers/statins, hold ACEi/ARB and diuretics morning of surgery, stop SGLT2 inhibitors 3–4 days early, stop GLP-1 agonists per dosing schedule, manage anticoagulation by bleeding/thrombotic risk balance, and never start beta-blockers day of surgery.

Optimize active conditions before elective surgery: decompensated HF, unstable CAD, severe symptomatic valvular disease, significant arrhythmia, poorly controlled DM (HbA1c >9%), iron-deficiency anemia, untreated OSA, and substance use — each has a specific intervention with a specific timeline.

Special situations demand specific moves: pheochromocytoma needs alpha- then beta-blockade; pregnancy elective surgery defers to second trimester; cirrhosis with MELD >15 is high-risk; DNR in the OR requires explicit conversation; recent DES mandates ≥6 months DAPT before elective surgery.

After surgery: secondary prevention bundle (aspirin, statin, beta-blocker, ACEi where appropriate), cardiac rehab referral if periop MI, structured follow-up cadence, and medication reconciliation at every transition — the single highest-yield patient-safety intervention across the perioperative continuum.