Preoperative Recommendations / Guidelines

Fairview Health Services 6/2009

The following recommendations are the product of a multidisciplinary group* charged with coming
up with standardized recommendations to guide the preoperative evaluation of patients before
surgery. These recommendations are made to help establish systems to aid in appropriate
preparation of patients for surgery. They may be used to set up EHR reminders or clinic and
hospital work flows. However, clinical judgment supersedes these recommendations (e.g. No
mention is made, but clearly severe COPD may call for ABGs prior to surgery, or sleep study if
severe sleep apnea suspected but not diagnosed, or BB may not improve risk if relatively low risk
surgery and only one lower level risk factor such as HTN).

*The Development Group:

Michael Dummer, MD (Lakes, IM) Joel Arney, MD (Ridges, Anesthesiology)
Danielle Doro, MD (Crosstown Clinic, IM) Joe Arcuri, MD (UMP, IM)
Angela Fitch, MD (Eagan Clinic, IM) Mike Aylward, MD (UMP, IM/Peds)
Mark Nomura, MD (Southdale, Sara Frankwick, MD (FP, Maple Grove)
Anesthesiology) Beverly Christie, DNP, RN (Director of
Barbara Gold, MD (UMMC, Anesthesiology) Clinical Knowledge)
Kent Svee, MD (Lakes, IM) Milena Ninkovic, MD (IT Knowledge
Barry Bershow, MD (Ambulatory QIC) Engineer)
David Kaisaki, MD (Northeast Clinic, IM) Jackson Thatcher, MD (cardiology, Park
James Bergstrom, MD (CPMC, IM) Nicollett)
Laura Stoiber, MD (Lakes, surgery) David Laxson, MD (cardiology, MN Heart)
~ Reviewed by the System Clinical Pharmacy Committee

I. CARDIOVASCULAR RISK MODIFICATION

A. Preoperative Beta Blockers Recommendations* (Thatcher, 2006, Fleisher, 2007, ICSI,
2008)

1 Patients on chronic beta-blocker therapy should continue taking their beta-blocker

medication up to and including the day of surgery.
2 Beta-Blockers are recommended to be started for patients who have DM, HTN, IVD,
(cerebrovascular disease, CAD, PVD) AF, CHF for intermediate and high risk surgeries. May be
indicated for other patients with high risk of cardiac disease (i.e. combination of age, smoker, high
cholesterol, family history).
3 Start Beta-blockers as soon as possible as outpatient and titrate dose to resting target pulse 55-
65. If time does not allow additional follow-up or titration, start Beta-blocker and communicate the
initiation to anesthesia/surgery. It should not be necessary to cancel or postpone surgery solely for
the institution of Beta-Blocker.
• For patients starting a beta-blocker prior to surgery we recommend using Metoprolol succinate
XR 100mg daily. (Consider ½ the dose if patient is small, frail, elderly or resting heart rate of <
65 or systolic BP of < 110)
Instruct patient to take pulse or have them come in for nurse pulse check and advise to
increase dose if pulse >70.
• Continue the Beta-Blocker for 2-4 weeks after surgery.
4 If heart rate is not controlled with current dose, maximizing heart rate control should be attempted
if on it for the above indications.
5 Considerations:
• Start at the above recommended dose and instruct patient to take pulse or have them come in
for nurse pulse check and advise to increase dose if pulse >70.
Beverly Christie, DNP, RN 1
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 6 Potential contraindications or not recommended in patients who:
• Need emergent surgery
• Have an allergy to beta-blockers
• Have bradycardia (HR < 50)
• Advanced heart block (greater than one first-degree AV block) unless treated by pacemaker
• Severe bronchospasms/COPD/asthma/reactive airway disease
• For patients undergoing only Low Risk Procedures: see grid below

Cardiac Risk* Stratification for Noncardiac Surgical Procedures

High (Reported cardiac risk Intermediate (Reported cardiac risk Low† (Reported cardiac risk generally less
often greater than 5%) generally less than 5%) than 1%)
Emergent major operations, Carotid endarterectomy Endoscopic procedures
particularly in the elderly Head and neck surgery Superficial procedure
Aortic and other major vascular Intraperitoneal and intrathoracic Cataract surgery, most
surgery surgery Ophthalmologic procedures
Peripheral vascular surgery
Anticipated prolonged surgical
Orthopedic surgery Breast biopsy
procedures associated with large Prostate surgery Removal of minor skin or
fluid shifts and/or blood loss subcutaneous lesion
Myringotomy tubes
Hysteroscopy
Cystoscopy
Fiberoptic bronchoscopy

*Combined incidence of cardiac death and nonfatal myocardial

7 Beta-Blockade and Heart Failure:

• Two beta-blockers have demonstrated efficacy in heart failure patients: Metoprolol (MERIT-HF)
and Carvedilol (COPERNICUS). (Bisoprolol has also shown benefit but it not widely available in
the United States)
Patients with systolic dysfunction (EF < 40%) should be on Metoprolol succinate
(Toprol) or Carvedilol (Coreg) preoperatively, provided they do not have a
contraindication.
Atenolol is a suitable alternative for patients with diastolic heart failure (EF> 40%)
Recommended dose would be Metoprolol succinate 100mg daily

*The workgroup recognized that there are many divergent recommendations regarding the best inclusion protocol for beta-
blocker therapy, but that we needed to come to a definitive recommendation in order to facilitate EHR reminders, work flows and
standards to support the use of Heart Rate control for risk reduction across Fairview sites. .

Beverly Christie, DNP, RN 2

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 B. Active Cardiac Conditions (see algorythm below) Cardiology Consultation
Recommended: (Thatcher, 2005, Fleisher, 2007, ICSI, 2008)
1 Unstable coronary disease: Unstable or severe angina, Recent MI (I 1 month)
2 Decompensated HF: NYHA class IV, worsening or new onset HF
3 Certain arrhythmias: High-grade AV block, Mobitz II, 3rd degree AV block, Symptomatic ventricular
arrhythmias, SVT or A-fib with uncontrolled rate, symptomatic bradycardia, new V-tach
4 Severe valvular disease: Severe AS (mean pressure gradient >40mm, valve area<1.0cm, or
symptomatic) Symptomatic mitral stenosis (increasing SOB, presymcope or HF)

C. Stress Testing Guideline: (Thatcher, 2006, Fleisher, 2007, ICSI, 2008)

1 Stress testing may be considered if:
• clinical evaluation suggests need for stress testing independent of impending surgery (e.g.
undiagnosed chest pain, long history of poorly controlled DM, or in some instances monitoring
of patients after recent revascularization)
• vascular or high risk surgery plus 3 or more risk factors, which include:
DM
CHF
IVD (CAD, PVD, Thrombotic Cerebrovascular disease)
Cr>2
Poor functional capacity (<4METs)
2 Current evidence does not support a strategy of routine revascularization in stable patints as a
strategy to reduce morbidity/mortality (McFalls, et al., 2004, Poldermans, et al., 2006). Stress
testing is therefore primarily recommended for indications that would be valid independent of the
proposed surgery. Stress testing may however be indicated, especially for high risk but elective
surgeries (i.e., major spine surgery), to assist in the determination of risks vs. benefits, as well as
determining perioperative monitoring strategies.
3 Functional status < 4METs should be seen as a primary risk factor (see table 3 below). If a patient
has an impending high risk surgery with prolonged procedure or significant fluid shifts, this can be
seen as a significant aerobic challenge. Stress testing can help determine the patient's ability to
tolerate that kind of stress. If the decision is made to proceed to preoperative stress testing,
consensus of the committee recommended stress imaging (Stress echo, dobutamine stress echo,
stress cardiolyte, or adenosine cardiolyte ) to improve sensitivity and specificity.

Table 3. Estimated Energy Requirements for Various Activities

Can you….
Can you….
Climb a flight of stairs or walk up a hill?
1 MET Take care of yourself? 4 METs
Walk on level ground at 4 mps (6.4 kph)?
Eat, dress, or use the toilet?
Run a short distance?
Walk indoors around the house?
Do heavy work around the house like
Walk a block or 2 on level ground at 2 to scrubbing floors or lifting or moving heavy
3 mph (3.2 to 4.8 kph)? furniture?

Participate in moderate recreational

Do light work around the house like activities like golf, bowling, dancing, doubles
4 METs
dusting or washing dishes? tennis, or throwing a baseball or football?

Participate in strenuous sports like

Greater than 10 METs swimming, singles tennis, football,
basketball, or skiing?
Kph indicates kilometers per hour: MET, metabolic equivalent and mph, miles per hour.
*Modified from Hlatky et al. (10) copyright 1989, with permission from Elsevier, and adapted from Fletcher, et al. (11).

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 1. ACC/AHA perioperative guidelines:

ACC /AHA Perioperative Guidelines

Perioperative surveillance
and postoperative risk
Need for emergency Yes Operating room
Step 1 stratification and risk factor
noncardiac surgery? (Class I, LOE C)
management

No

Evaluate and
treat per Consider
Active Cardac Yes
Step 2 ACC/AHA operating room
conditions* (Class I, LOE B)
guidelines

No

Proceed with
Low risk surgery Yes
Step 3 planned
(Class I, LOE B)
surgery

No

Good functional capacity

Step 4 (MET level greater than or Yes Proceed with
equal to 4) without (Class I, LOE B) planned surgery
symptoms

Step 5 No or unknown

3 or more clinical 1 or 2 clinical risk

risk factors factors No clinical
risk factors
Vascular Intermediate
surgery risk surgery
Vascular Intermediate Class I,
surgery risk LOE B
Class IIa
surgery
LOE B

Proceed with
Consider testing if it planned surgery
will Proceed with planned surgery with HR control (Class ll a, LOE B)
change management or consider noninvasive testing (Class ll b, LOE B) if it will change
management.

Risk factors include history of CAD, CHF, IVD, DM, Renal insufficiency.

Figure 1. Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac
risk factors for patients 50 yrs of age or greater. Clinical risk factors include ischemic heart disease, compensated or prior heart failure, diabetes
mellitus, renal insufficiency, and cerebrovascular disease. Consider perioperative beta blockade for populations in which this has been shown to
reduce cardiac morbidity/mortality. ACC/AHA indicates American College of Cardiology/American Heart Association; HR, heart rate; LOE, level of
evidence; and MET, metabolic equivalent.

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 D. Echocardiogram recommendations
1 For evaluation of LV function;
• Dyspnea of unknown origin to evaluate LV function.
• Pts with current or prior heart failure with worsening dyspnea or other change in clinical status –
if not done within 12 months to undergo preoperative evaluation of LV
• Reassessment of LV function in clinically stable patients with previously documented
cardiomyopathy is not well established.
2 For evaluation of cardiac murmurs:
• For the following murmurs in asymptomatic patients
Diastolic murmurs
Continuous murmurs
Late systolic murmurs
Murmurs associated with ejection clicks
Murmurs that radiate to the neck or back
Grade 3 or louder midpeaking systolic murmurs
• For symptomatic patient with murmurs
Murmurs associated with other abnormal physical findings on cardiac examination
Murmurs associated with an abnormal electrocardiogram or chest x-ray
• Echocardiograms are not indicated for asymptomatic 2/6 midsystolic murmurs considered
innocent or functional.

II. PULMONARY RISK MODIFICATION (Qaseem, et al.,2006, Smethana, et al., 2006)

1 Maximize COPD treatment
2 Treat acute lung disease before surgery
3 Use stress dose steroids when appropriate
4 Maximize nutrition
5 Utilize Pulmonary Rehab when available
6 Advise smoking cessation to improve COPD outcomes (but literature suggests no evidence of
change of surgical outcome)
7 Consider measuring serum albumin if the need to define pulmonary risk is high. Values below 35
grams / liter are the most predictive marker of pulmonary risk
8 Consider not having surgery when risk is high
Risk Calculations:
a. Determine presence of risk factors for pulmonary complications (numbers in parentheses refer to
pooled odds ratios)
• COPD (not Asthma) (2.3)
• Age over 60 (2.28-5.63)
• ASA class II or greater (a patient with at least mild systemic disease) (4.87)
• Congestive heart failure (2.93)
• Need for assistance with activities of daily living (including use of assistive devices) (1.65-2.51)
• Minor risk factors (impaired sensorium, abnormal x-ray, alcohol use, unexplained weight loss)
(<1.5)
b. Determine the surgical risk for pulmonary complications
• Prolonged surgery (>3 hours) (2.26) • Vascular surgery (2.10)
• Abdominal Surgery (3.09) • Aortic Aneurysm repair (6.9)
• Thoracic surgery (4.24) • Emergency surgery (2.52)
• Neurosurgery (2.53) • General Anesthesia (2.35)
• Head and Neck Surgery (2.21)

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III. OBSTRUCTIVE SLEEP APNEA (Kaw, et al., 2006)

A. Few definitive data exist to guide the perioperative management of patients with known sleep
apnea and those suspected of having this condition. Heightened awareness and the close
monitoring of high risk patients is recommended. Anesthetic, sedative and analgesic drugs
should be used with extreme caution in patients with OSAS or in those suspected of having OSAS
who are to undergo surgery. Nasal CPAP therapy before and after surgery may improve
outcomes in these patients, though further study is needed.
B. Patients with sleep apnea should be encouraged to bring their CPAP machine with them to
surgery, in case this is required for a hospital stay.

IV. PREOPERATIVE LAB TESTING (ICSI, 2008, Fletcher, et al., 2007)

A. Pre-op Lab, EKG and X-ray recommendations

General recommendations for Pre-op testing

1 Unless high risk procedure (cardiac, aortic, peripheral vascular, prolonged or high blood loss
procedures (i.e. Whipple, major spine surgery, bariatric surgery), routine lab screening is
generally not recommended, except as determined by H&P.
2 Labs / procedures need to be obtained to follow the disease processes identified in the
history:
• Hgb—Hgb or CBC indicated if history of anemia or significant blood loss a possibility with
the intended surgery (Tonsillectomy, major intraperitoneal surgery, vascular surgery, major
spine surgery)
• K+—If on diuretics or Digitalis, HTN, CKD, etc.
• Cr—If CKD, DM, HTN, CHF, etc.
• A1c – On diabetics if not done in the last 60-90 days
• Coags—if on anticoagulants or clinical suspicion of coagulopathy. Preop Coags are not
necessary for routine use of short term anticoagulation post op. “There is no evidence to
support routine checking of coagulations studies unless clinical circumstance suggests a
potential bleeding problem.”
• CXR—If signs or symptoms of unstable cardiopulmonary disease (otherwise not covered
by insurance)
• EKG
Any patient having vascular surgery.
If not done in last year and DM, HTN, CHF, smoking, IVD, morbid obesity or chest pain
If not done in the last year and age > 55
If not done in the last 30 days and history of CAD, or any vascular surgery
3 No labs for Cataract surgery unless needed for monitoring of other diseases
4 Lab Recommendations
• Labs should be drawn early enough to effectively identify modifiable risks. These may be
done at the time of the pre-op evaluation or surgical consult, generally within 2 weeks of
the surgery

Beverly Christie, DNP, RN 6

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V. MANAGEMENT OF ANITPLATELET AND ANTICOAGULATION
MEDS DURING SURGERY (Geerts, et al., 2008, Holger, et al., 2008, American Society
of Anesiologists, 2009)

Aspirin – can be continued before and after surgery for patients with a high thrombosis risk…such as
a recent stent or heart attack. It also should be continued for procedures with a low risk of bleeding...such
as minor dental, dermatologic, or cataract surgeries.
~ If aspirin is held, stop it 7 to 10 days prior to surgery instead of just 5 days...to minimize antiplatelet
effects.
Clopidogrel / Plavix – if used in post stent patients, especially drug deluding stents, should
NOT be stopped until okayed by cardiology (see figure 2 below). If used for other indications and
deemed necessary to stop, should be stopped 7 to 10 days before surgery.
Cilostazol (Pletal) – would need to be stopped two to three days prior to surgery.
NSAIDs – should be stopped about 5 half-lives before surgery. (e.g. one day for ibuprofen and 10
days for nabumetone)
NSAID Time to hold before surgery
Diclofenac (e.g., Voltaren) One day
Ibuprofen (e.g., Motrin)
Indomethacin (e.g., Indocin)
Ketoprofen (e.g, Orudis, Oruvail)
Celecoxib (Celebrex) Diflunisal (Dolobid; Novo- Two to three days before surgery
Diflunisal [Canada])
Naproxen (e.g., Naprosyn)
Sulindac (Clinoril; Novo-Sundac [Canada])
Meloxicam (Mobic) Ten days before surgery
Nabumetone (Relafen)
Piroxicam (Feldene; Pexicam [Canada])

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Place holder for final document WARFARIN Management of these patients depends on the risk of stopping
warfarin vs the bleeding risk of the specific surgery. See the table below for general guidelines. Fairview Anticoagulation
Clinics will help in determining the appropriate management of these patients if needed.
Fairview Health Services Anticoagulation Bridging Guide 2008
• • •

KEY:

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VI. MEDICATION RECOMMENDATIONS IN PREOP PERIOD
Take all prescription meds prior to surgery as regularly scheduled EXCEPT:

1 Glycemic control: For most patients the following guidelines are recommended by the
workgroup.
Hold all Regular, Lispro (Humalog), Aspart (Novolog) and Glulisine (Apidra) insulin the
morning of the procedure
Hold Byetta and Symlin AM of surgery (and similar injectables)
Hold A.M. dose of ORAL hypoglycemic drug
Give 80% of dose of LONG-ACTING insulin, which is Glargine (Lantus) or Detemir
(Levemir),
Give 66% (2/3) of the usual morning dose of INTERMEDIATE insulin (NPH)
Give 0 (none) of mixed insulins (70/30, 75/25, 50/50) to avoid the rapid component of these
insulins. May consider giving the patient some NPH and having them take 2/3 of their NPH
dose in AM
Insulin pump patients: should continue their basal rate up until the time of surgery.
Anesthesia will guide from there. Patients should be reminded to bring extra pump supplies
to surgery.
For patients on insulin, while fasting for procedures and tests, patients should be reminded
to:
• Monitor their BS every 4 hours
• If BS high, take corrective dose (not meal dose) sliding scale insulin if that is what
they are used to doing
• IF BS is <100 or symptoms of hypoglycemia follow the following guidelines:
Drink 4oz of fruit juice without pulp or 4oz of regular soda
Eat 3 glucose gels or 5 sugar cubes or packets
Monitor BS q15min until stable BS
• Repeat the treatment as needed and monitor BS until >100.

2 Antiplatelet and anticoagulants as recommended in the section above.

3 Consult rheumatology for disease modifying rheumatologic meds (e.g. Remicaid, Humera)
There is some emerging evidence that these drugs may impede healing and increase infection
risk.
• See table below

Table 1: Suggestions for Perioperative Management of Disease Modifying Antirheumatic Drugs (DMARDS,
unpublished) for Elective Orthopedic Surgery
Drug Usual dose Perioperative dosing
Nonbiologic DMARDs
Gold (oral) 6 to 9 mg per day in 1 or 2 doses Continue usual dose*
(i.m.) 10 to 50 mg every 1 to 4 weeks
Minocycline 200 mg per day in 2 to 4 doses Continue usual dose*
Sulfasalazine 500 to 3,000 mg per day in 2 to 4 doses Continue usual dose*
Antimetabolite/antiproliferative Nonbiologic DMARDs
Azathioprine 50 to 150 mg per day in 1 to 3 doses Suspend 1-7 days preoperatively, and up to 7 days
postoperatively**
Chlorambucil 2 to 8 mg per day in 1 to 2 doses Suspend 1-7 days preoperatively, and up to 7 days
postoperatively**
Cyclophosphamide 50 to 150 mg per day in 1 dose Suspend 1-7 days preoperatively, and up to 7 days
postoperatively**
Leflunomide 10 to 20 mg per day in 1 dose Suspend 2 weeks preoperatively, and up to 14 days
postoperatively
Methotrexate 7.5 to 20 mg per week in 1 dose Suspend 2 weeks preoperatively, and up to 14 days
postoperatively
Mycophenolate mofetil 500 to 2,000 mg per day in 1 to 2 doses Suspend 1-7 days preoperatively, and up to 7 days
postoperatively**

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Biologic Response Modifiers
Anti-tumor necrosis factor-- agents
Adalimumab 40 mg i.m. every 14 days in 1 dose Suspend 2 weeks preoperatively, and 1 to 2 weeks
postoperatively
Certolizumab NOT YET APPROVED
Etanercept 50 mg s.c. once every 7 days in 1 dose. Suspend 1 week preoperatively, and 1 to 2 weeks
postoperatively
Infliximab 3 to 5 mg/kilogram i.v. body weight Suspend 2 to 4 weeks preoperatively, and 2 to 4
every 6 to 8 weeks in 1 dose weeks postoperatively
Anti-Interleukin 1 agent
Anakinra 100 mg s.c. per day in 1 dose Suspend 1-7 days preoperatively, and 1 to 2 weeks
postoperatively
Anti-Interleukin 6 agent
Tocilizumab NOT YET APPROVED
Selective T-cell costimulation modulator inhibitor
Abatacept 500 to 1,000 mg i.v. every 4 weeks in Suspend 2 weeks preoperatively, and 2 weeks
one dose postoperatively
Selective B-cell inhibitor
Rituximab 1,000 mg i.v. given at two week interval; Elective surgery no sooner than 4 weeks following
subsequent dose 16-26 weeks following last dose, and at least 4 weeks preceding next dose
the initial dose of the drug
*It is not necessary to suspend these agents in the perioperative period, but they may be held for some days in the immediate postoperative
period according to patient and physician preference.
**These drugs may be used to manage and control serious extraarticular manifestations of rheumatic disease such as vasculitis. In such cases,
the decision to suspend their use perioperatively should be carefully weighed against the risk of loss of disease control and end organ damage.
i.m.= intramuscular i.v.= intravenous s.c.=subcutaneous

VII. STRESS DOSE STEROIDS (Cousin, 2002)

Table 1: Perioperative Glucocorticosteroid Supplementation

Glucocorticosteroids*
Surgical stress Glucocorticosteroid dose
25 mg of hydrocortisone or 5 mg of methylprednisolone IV on
Minor, not requiring sedation
day of surgery
50-75 mg hydrocortisone, or 10-15 mg methylprednisolone IV
Moderate, including sedation on day of procedure. Taper to baseline preoperative dose
over 1-2 days
100-150 mg of hydrocortisone or 20-30 mg
Severe, including sedation and major
methylprednisolone IV on day of procedure. Taper over 1-3
trauma
days to baseline preoperative dose
Critically ill, including septic shock and 50 mg of hydrocortisone IV every 6 hours with 50 mcg
sepsis-induced hypotension fludrocortisones daily for 7 days

*To be considered for all patients on chronic preoperative glucocorticosteroid therapy within 3-12 months
of surgery. Chronic steroids should be considered to include those patients on greater than 3
weeks of 20 mg or above in the last 3 months or continuous Prednisone greater than 5 mg
ongoing. Consider assessing adrenal stress response with cosyntropin testing for elective surgery if
adrenal function uncertain.

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REFERENCES
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Cousin DB, Wood KE (2002). Corticosteroid supplementation for adrenal insufficiency. JAMA, 287, 238-240.

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Qaseem, A., et al. (2006). Risk assessment for and strategies to reduce perioperative pulmonary
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Smetana, G.W., Lawrence, V.A., & Cornell, J.E. (2006). Preoperative pulmonary risk stratification for
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Thatcher, J.L., Gilseth, T.A., & Sticha, A. (2005). Observations on the effect of a perioperative beta
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