Preoperative Optimization Flowchart (Compact)

Preoperative Optimization Flowchart

Patient Scheduled for Surgery
Initiation of the perioperative pathway.
Initial Assessment & SDM Intro
Gather Information:
  • Medical/Surgical History (inc. prior anesthesia experience)
  • Comorbidities
  • Medications (Rx, OTC, Herbals) & Allergies
  • Social History (Smoking, Alcohol, Drugs)
  • Baseline Functional Status
  • Physical Examination
  • Review relevant investigations
Shared Decision Making (SDM): Introduce concept, patient preferences & goals. (NICE NG180)
Risk Stratification
Assess Combined Risk:
  • Surgical Risk: Low (<1% MACE) vs. Elevated (≥1% MACE). (AHA/ACC 2024)
  • Patient Risk Factors: Use validated tools (e.g., RCRI, NSQIP) & clinical judgment. Identify CAD, HF, Diabetes, CKD, etc. (AHA/ACC 2024, BJHM Review)
  • Functional Capacity: Structured assessment (e.g., DASI) or METs. Poor = <4 METs or DASI ≤34. (AHA/ACC 2024, ACP Review, METS Study)
  • Frailty Assessment: Clinical judgment, scales (e.g., CFS). (Frailty Review)
  • ASA Status: Assign ASA Physical Status Classification. (CAS Guidelines)
Further Eval Needed?
Based on combined surgical & patient risk, functional capacity, and specific concerns (e.g., unstable symptoms). Generally indicated for elevated risk surgery + elevated patient risk/poor functional capacity. (AHA/ACC 2024)
No (Low Risk / Stable) Yes (Elevated Risk / Concerns)
Routine Optimization
Focus on standard preoperative prep: medication review, lifestyle advice, fasting instructions.
Targeted Evaluation
Consider based on specific risks (AHA/ACC 2024):
  • Biomarkers: BNP/NT-proBNP, Troponin (Reasonable for high risk pts, outcomes impact unclear).
  • ECG: If known CVD, symptoms, or elevated risk surgery.
  • Echocardiogram: If HF symptoms/signs, suspected valve disease.
  • Stress Testing: If elevated risk + poor/unknown functional capacity.
Consults: Cardiology, Pulmonology, etc. as needed.
Intensive Optimization
Address findings from targeted evaluation. May require more significant interventions or delays.
Optimization Phase (Iterative)
Address Modifiable Factors & Plan Perioperative Care:
  • Comorbidity Management:
    • Cardiac: Follow AHA/ACC recs (HTN control, HF meds except SGLT2i, stable CAD).
    • Diabetes: Optimize HbA1c (<69), plan insulin/med adjustments (CPOC).
    • Anemia: Treat Fe deficiency (Oral/IV Iron), transfuse if needed (Hb<8 threshold common). (NICE)
    • Pulmonary: Smoking cessation, inhaler optimization.
    • Frailty: Nutrition support, prehab, CGA if applicable.
    • Nutrition: Screen & support if malnourished.
  • Medication Management:
    • Review ALL meds.
    • Hold/Continue per guidelines (e.g., Continue Beta-blockers/Statins, Hold ACEi/ARBs? Hold SGLT2i 3-4d, Hold DOACs based on risk/CrCl, Bridge Warfarin rarely). (AHA/ACC, Trinity, Froedtert)
    • Plan VTE prophylaxis. (NICE)
  • Lifestyle/Prehabilitation: Smoking cessation (>4-8 wks ideal), alcohol reduction, exercise program, psychological support. (NICE, CPOC Prehab)
  • Shared Decision Making (SDM): Ongoing discussion of risks, benefits, alternatives (BRAN), patient values. Confirm understanding. (CPOC, AUA)
Optimized & Ready?
Has the patient reached optimal baseline? Are risks acceptable and understood? Is the plan agreed upon via SDM?
Yes No / Re-evaluate
Proceed to Surgery
Patient proceeds with planned surgical procedure following final checks (fasting, consent).
Continue Optimization / Reconsider Plan
  • Continue optimization efforts if more time feasible.
  • Re-evaluate risks/benefits via SDM.
  • Consider alternative treatments (less invasive surgery, non-operative management).
  • May loop back to Optimization Phase.
Non-Operative Management / Alternative
Decision made via SDM to pursue non-surgical options or significantly different surgical approach.