Preoperative Evaluation Contributors CONSULTING EDITOR LEE A. FLEISHER, MD, FACC, FAHA Robert D. Dripps Professor and Chair of Anesthesiology and Critical Care, Professor of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania EDITORS DEBRA DOMINO PULLEY, MD Associate Professor, Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri DEBORAH C. RICHMAN, MBChB, FFA(SA) Section Chief and Director, Pre-operative Services, Clinical Associate Professor, Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook Medicine, Stony Brook, New York AUTHORS MATTHIAS BOCK, MD, Priv-Doz Department of Anesthesia and Intensive Care Medicine, Central Hospital, Bolzano, Italy; Department of Anesthesiology, Perioperative Medicine and Intensive Care, Paracelsus Medical University, Salzburg, Austria ARVIND CHANDRAKANTAN, MD, MBA, FAAP Clinical Assistant Professor of Anesthesiology, Stony Brook University Medical Center, Stony Brook, New York BEVERLY CHANG, MD Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Hospital and Clinics, Stanford, California ANA COSTA, MD Clinical Assistant Professor, Department of Anesthesiology, Stony Brook Medicine, Stony Brook, New York ANGELA F. EDWARDS, MD Associate Professor of Anesthesiology, Section Head of Perioperative Medicine, Wake Forest Baptist Health, Wake Forest University School of Medicine, Winston Salem, North Carolina LEE A. FLEISHER, MD, FACC, FAHA Robert D. Dripps Professor and Chair of Anesthesiology and Critical Care, Professor of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania iv Contributors GERHARD FRITSCH, MD, Priv-Doz Department of Anesthesiology, Perioperative Medicine and Intensive Care, Paracelsus Medical University, Salzburg, Austria; Department of Anesthesiology and Intensive Care, UKH Lorenz Boehler, Vienna, Austria TONG J. GAN, MD, MHS, FRCA Professor and Chair, Department of Anesthesiology, Health Science Center, Stony Brook University School of Medicine, Stony Brook, New York RUCHIR GUPTA, MD Assistant Professor, Department of Anesthesiology, Health Science Center, Stony Brook University School of Medicine, Stony Brook, New York DAVID L. HEPNER, MD, MPH Department of Anesthesiology, Perioperative and Pain Medicine; Associate Director, Weiner Center for Preoperative Evaluation, Brigham and Women’s Hospital; Associate Professor of Anaesthesia, Harvard Medical School, Boston, Massachusetts RICHARD HUH, MD Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois SELMA ISHAG, MBBS, MD Assistant Professor, Division of General Anesthesiology, Barnes-Jewish Hospital, Washington University, St Louis, Missouri AMIR K. JAFFER, MD, MBA Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois ANKIT J. KANSAGRA, MD Chief Fellow, Department of Hematology/Oncology, Baystate Medical Center, Tufts University, Springfield, Massachusetts JISU KIM, MD, MSc Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois JUSTIN G. KNITTEL, MD Instructor, Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri ANAND LAKSHMINARASIMHACHAR, MBBS, FRCA Assistant Professor of Anesthesiology, Division of Cardiothoracic Anesthesiology, Barnes-Jewish Hospital, Washington University School of Medicine in St Louis, St Louis, Missouri HEATHER McKENZIE, MD Instructor in Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri JOSHUA D. MILLER, MD, MPH Assistant Professor of Medicine, Endocrinology and Metabolism, Department of Medicine, Stony Brook Medicine, Stony Brook, New York DEBRA DOMINO PULLEY, MD Associate Professor, Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri Contributors v DEBORAH C. RICHMAN, MBChB, FFA(SA) Section Chief and Director, Pre-operative Services, Clinical Associate Professor, Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook Medicine, Stony Brook, New York TRACIE SAUNDERS, MD, MDiv Professor of Anesthesiology, Stony Brook University Medical Center, Stony Brook, New York BARBARA SLAWSKI, MD, MS, FACP, SFHM Associate Professor of Medicine and Orthopaedic Surgery, Chief, Section of Perioperative and Consultative Medicine, Department of Medicine, Froedtert Hospital Clinical Cancer Center, Froedtert and Medical College of Wisconsin, Milwaukee, Wisconsin GERALD W. SMETANA, MD Professor of Medicine, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts MIHAELA S. STEFAN, MD Academic Hospitalist; Clinician Researcher; Director, Perioperative Clinic and Medical Consultation, Division of Hospital Medicine, Department of General Medicine, Tufts University, Springfield, Massachusetts CHARUHAS V. THAKAR, MD, FASN Professor of Medicine, Director, Division of Nephrology, Kidney CARE Program, University of Cincinnati; Chief, Renal Section, Cincinnati VA Medical Center, Cincinnati, Ohio STEPHAN R. THILEN, MD, MS Assistant Professor, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington MIRIAM M. TREGGIARI, MD, PhD, MPH Professor, Director of Clinical Research, Departments of Anesthesiology and Perioperative Medicine, and Public Health and Preventive Medicine, Oregon Health and Science University, Portland, Oregon RICHARD D. URMAN, MD, MBA Associate Professor of Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts DUMINDA N. WIJEYSUNDERA, MD, PhD, FRCPC Li Ka Shing Knowledge Institute of St Michael’s Hospital; Associate Professor, Department of Anesthesia, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada TROY S. WILDES, MD Assistant Professor, Department of Anesthesiology, Washington University School of Medicine in St Louis, St Louis, Missouri Preoperative Evaluation Contents Foreword: Preoperative Evaluation—Can We Really Make a Difference in Outcomes? xiii Lee A. Fleisher Preface: Preoperative Evaluation xv Debra Domino Pulley and Deborah C. Richman Section I: Introductory Articles Preoperative Clinics 1 Angela F. Edwards and Barbara Slawski Preoperative evaluation clinics have been shown to enhance operating room efficiency, decrease day-of-surgery cancellations, reduce hospital costs, and improve the quality of patient care. Although programs differ in staffing, structure, financial support, and daily operations, they share the common goal of preoperative risk reduction in order for patients to pro- ceed safely through the perioperative period. Effective preoperative eval- uation occurs if processes are standardized to ensure clinical, regulatory, and accreditation guidelines are met while keeping medical optimization and patient satisfaction at the forefront. Although no universally accepted standard model exists, there are key components to a successful preop- erative process. Preoperative Consultations 17 Stephan R. Thilen, Duminda N. Wijeysundera, and Miriam M. Treggiari Preoperative consultation is an important intervention that likely has most benefits for intermediate-risk to high-risk patients undergoing major sur- gery. Consultation rates are likely increasing and there is significant practice variation in the use of consultation. Consultations should be available within a well-organized and coordinated process of preoperative assessment. Preoperative consults should be accessible to anesthesia and surgical teams involved in the procedure and to the providers involved in postoper- ative care. The role of preoperative consultation should evolve as a rational approach and emerge as a value-based service. New payment methodolo- gies are likely to facilitate appropriate use of this important resource. Perioperative Ethical Issues 35 Arvind Chandrakantan and Tracie Saunders Shared decision-making is a paradigm of patient engagement that is assuming greater importance in the era of value-based health care. The basic tenets include patient engagement on clinical decisions, taking into account multiple factors that influence physician and patient viii Contents decision-making. Understanding and reconciling diametrically opposed views of care are important tenets of shared decision-making. Because many decisions are made preoperatively, the applicability of these princi- ples may be useful especially in the situation of a higher risk surgical candi- date. Many patients with Do-Not-Resuscitate (DNR) orders are undergoing procedures to improve quality of life. This article explores shared decision- making and DNR. Preoperative Laboratory Testing 43 Matthias Bock, Gerhard Fritsch, and David L. Hepner Routine preoperative testing is not cost-effective, because it is unlikely to identify significant abnormalities. Abnormal findings from routine testing are more likely to be false positive, are costly to pursue, introduce a new risk, increase the patient’s anxiety, and are inconvenient to the patient. Abnormal findings rarely alter the surgical or anesthetic plan, and there is usually no association between perioperative complications and abnormal laboratory results. Incidental findings and false positive results may lead to increased hospital visits and admissions. Preoperative testing needs to be done based on a targeted history and physical examination and the type of surgery.