The Top 5 Clearance Problems Before Surgery

Your patient has spent hours getting ready for surgery. You have explained the procedure to them, verified their insurance and made sure they had access to post-operative care. The medical clearance report is complete with a recommendation for "delay surgery". This is frustrating for both your patient and you.

Potential medical clearance issues can be identified quickly and easily.

Predicting abnormalities in electrolytes

An examination of a patient's medications list can often help to predict electrolyte disturbances. Because it is difficult to identify asymptomatic kidney impairment in this setting, many guidelines don't recommend routine screening with a basic metabolic panel (BMP) or renal function panel (RFP). These laboratory screens can be used to help a surgeon identify electrolyte problems and fix them before they become a concern in the immediate postoperative period.

In addition, patients with renal impairment are more likely to die from postoperative complications such as pneumonia. This is a key factor in risk stratification. These lab results will allow the pharmacists and anesthesiologists to adjust medication dosages for patients with underlying renal impairment.

Preoperative Anemia

A complete blood count (CBC), which is used to diagnose anemia after surgery in an asymptomatic patient, can be done in less than 1% of cases. Anemia is a common postoperative problem that can be difficult to diagnose without a baseline. Preoperative hemoglobin and postoperative hematocrit are important predictors for mortality.

Although data aren’t conclusive the mortality risk associated anemia could be reduced by correcting preoperative anemia. If nerve block or regional anesthesia is used, a CBC will also provide a platelet count.

Blood pressure control

About one-third of American adults are hypertensive, despite the recent relaxed blood pressure goals. Hypotension can also delay a procedure. To reduce the risk, it is important to be familiar with how to administer home medication to patients.

Beta blockers and some blood pressure medications, including beta blockers can be beneficial for cardiac health and should be continued on the day before surgery. However, diuretics can complicate fluid optimization and should not be taken on that day. An internist can help optimize a patient's blood pressure and make sure that the operating room is ready for them if they are not well controlled.

Managing respiratory condition

Although pulmonary disease is more common among the elderly, it is vital to know every patient's baseline status before undergoing surgery. It is best to measure the patient's ability of expending energy before they become short of breath. This method is most commonly used and well-validated.

To quantify energy required to do daily activities, the metabolic energy equivalents (METs), are used. Multiple studies have shown that 4 METs is sufficient to do light housework, climb stairs or walk at 4 miles an hour without feeling short of breath. This allows for minimal risk to the lungs.

A screening radiograph is recommended by the American College of Physicians for patients with known cardiac disease. A radiograph, when combined with a physical examination, can often be used to help determine whether further intervention is necessary before surgery.

Detecting active heart conditions

All orthopaedic procedures have a reported risk of cardiac complications. An EKG is recommended for patients with known cardiac conditions such as arrhythmias and coronary artery disease, peripheral arterial disease, cerebrovascular diseases, cerebrovascular disease, structural or valvular disease.

American College of Cardiology has developed guidelines and risk stratification tables that help determine if a patient is ready to go for surgery. The most common reason that a surgery is delayed is because of active cardiac conditions. These include acute myocardial injury within the last 30 day, severe valvular disease or unstable arrhythmia. These conditions are often detected through a detailed history and physical exam and should be evaluated by a cardiologist before the patient is undergoing orthopaedic surgery.