Preoperative Care of the Gynecologic Patient
Victoria L. Handa
Preoperative care is a critical factor in achieving successful outcomes of both emergent and scheduled gynecologic surgical procedures. This chapter is designed to address the essential features of preoperative care from the preoperative examination in the office, or emergency room, to the time of surgery. Included are suggestions relating to appropriate preoperative testing and evaluation. Foremost, it is essential to keep in mind that each woman must be considered individually, based on her medical findings and needs, and that no suggestions can be completely adapted to all women preparing for gynecologic surgery.
The goals of the preoperative evaluation are to answer the following three questions, as outlined by Roizen:
Is the patient in optimal health?
Can, or should, the patient’s physical or mental condition be improved before surgery?
Does the patient have health problems or use any medications that could unexpectedly influence perioperative events?
PREOPERATIVE COUNSELING
It is most important to dedicate a portion of the preoperative care time to a discussion with the patient of options for management of her gynecologic problem, including both shortand long-term potential complications. All patients must be given sufficient medical information to allow them to make an educated decision about whether to proceed with the planned surgery. Not only is the discussion time useful in fostering a good physician-patient relationship, but it becomes extremely important if outcomes of surgery are less than expected, particularly if the discussion was documented in the patient’s record. The informed consent process should include patient education regarding the goals of the planned surgery, the alternatives, and the possible hazards. The preoperative discussion is also an opportunity to discuss expectations for the recovery period, including the expected duration of hospitalization and recommended activity restrictions for the postoperative period. This is also an opportunity to review the patient’s wishes regarding advanced directives.
SCREENING FOR PERIOPERATIVE RISK
Once a decision has been made to proceed with surgery, it is the responsibility of the surgeon to assess the patient for medical and surgical conditions that could increase her risk of complications. The most important part of the evaluation is the history. A screening questionnaire may also be of value (Table 8.1). The goal is to detect preexisting conditions shown to be associated with perioperative adverse events. Women with these risk factors should be further evaluated. Depending on the complexity of the situation, the surgeon may partner with the patient’s primary physician or with consultants to provide additional evaluation and management.
The risks of perioperative morbidity and mortality are strongly associated with the type of surgery planned. For example, the risk of cardiac death or myocardial infarction is 1% to 5% after major intraperitoneal surgery but less than 1% for ambulatory surgeries. Thus, the extent of the planned surgery, the nature of the pathologic condition indicating surgery, and the impact of any planned adjuvant treatments should be considered.
Risk factors for major cardiac complications (including myocardial infarction, pulmonary edema, ventricular fibrillation, cardiac arrest, and complete heart block) are well established. These risk factors include history of prior myocardial infarction, heart failure, cerebrovascular disease, insulin-dependent
diabetes, and serum creatinine >2.0 mg/dL. Among gynecologic surgery patients with none of these risk factors, the risk of a major cardiac complication is less than 1%. Other important factors include the age of the patient, dependent functional status (defined as unable to perform activities of daily living without assistance), and American Society of Anesthesiologists’ class (Table 8.2). The patient’s exercise tolerance can be used as a guide: Poor exercise tolerance is defined as inability to walk four blocks or to climb two flights of stairs as a part of normal daily activities. A more diligent preoperative evaluation is appropriate for women at high risk, possibly including exercise stress test and referral for cardiology evaluation.
diabetes, and serum creatinine >2.0 mg/dL. Among gynecologic surgery patients with none of these risk factors, the risk of a major cardiac complication is less than 1%. Other important factors include the age of the patient, dependent functional status (defined as unable to perform activities of daily living without assistance), and American Society of Anesthesiologists’ class (Table 8.2). The patient’s exercise tolerance can be used as a guide: Poor exercise tolerance is defined as inability to walk four blocks or to climb two flights of stairs as a part of normal daily activities. A more diligent preoperative evaluation is appropriate for women at high risk, possibly including exercise stress test and referral for cardiology evaluation.
TABLE 8.1 Preanesthetic Screening Questionnaire | ||||||||||||||||||||||||||||||||||||
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TABLE 8.2 Classification of Physical Status, Established by the American Society of Anesthesiologists | ||||||||||||||||
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Diabetes mellitus is a potential risk factor for cardiovascular morbidity and perioperative infections. The risk of surgical site infection is higher among women with preoperative serum glucose >200 mg/dL. The risk of infection is also significantly increased by postoperative hyperglycemia. In addition, an assessment for end-organ failure (such as renal or cardiac disease) is appropriate for women with long-standing diabetes, and especially those with a history of poor control and those with other sequelae from their diabetes.
Clinically significant pulmonary complications occur in 5% to 10% of surgeries. In a systematic review, Smetana and colleagues found that risk factors for pulmonary complications include age over 50 years, functional dependence (requiring assistance to perform activities of daily living), obstructive sleep apnea, surgery lasting greater than 3 hours, and cigarette smoking. Smoking duration is also a risk factor for perioperative complications. Well-controlled asthma is not a risk factor for perioperative pulmonary complications.
VALUE OF SCREENING LABORATORY STUDIES AND OTHER TESTING
The practice of a routine battery of preoperative laboratory tests is no longer recommended. Using data from National Surgical Quality Improvement Program, Benarroch-Gampel and colleagues demonstrated that the patient’s medical history, age, and the type of surgery planned are better predictors of surgical complications than are the results of laboratory tests. Similar findings were obtained by Fritsch and colleagues. The indiscriminate use of “routine” preoperative tests not only fails to identify high-risk patients but also leads to unnecessary costs. Also, false-positive results can lead to unnecessary surgical delays and interventions. Thus, preoperative tests should not be ordered routinely but should be based on the characteristics of the patient and the planned surgery.
Preoperative testing recommendations at Johns Hopkins Bayview Medical Center are summarized in Table 8.3. Testing recommendations for gynecologic surgery are based on the patient’s risk factors, which are derived from the history and physical examination. Coagulation studies are rarely recommended prior to gynecologic surgery but may be considered for those with menorrhagia, if clinically indicated. Chest x-ray is indicated only if the patient has experienced a recent acute episode of respiratory distress or flare of chronic pulmonary disease. A urine pregnancy test is obtained on the day of surgery for women who, by history, may be pregnant. Tests that have been performed recently (within 6 months) should not be repeated if the patient’s condition has not changed. This is because the result is unlikely to be different; Macpherson and colleagues found a less than 1% probability of an abnormal laboratory test result in an adult with a normal value within the past year.
Preoperative hematocrit (or complete blood count) is probably the most commonly used preoperative laboratory study. Baseline hemoglobin can be useful in the interpretation of postoperative anemia and the management of patients with acute surgical blood loss. Therefore, a preoperative hematocrit should be ordered if the planned surgery is likely to result in substantial blood loss or if the patient’s history suggests a high risk for preoperative anemia.
Serum electrolytes should not be ordered routinely but may be useful in women on diuretics or with a history that suggests an electrolyte imbalance is likely. A routine BUN and creatinine are appropriate for women with diabetes or hypertension. Routine BUN and creatinine may also be useful in older patients. Serum glucose is recommended for women on chronic corticosteroids.
A preoperative electrocardiogram should be considered in women with known cardiovascular disease, peripheral artery disease, or cerebrovascular disease. This is because a baseline electrocardiogram can be useful in the management of acute perioperative cardiovascular events. However, an electrocardiogram is a poor screening test and is unlikely to alter management in the asymptomatic patient. Routine preoperative electrocardiogram should be considered in women over age 50.
A cardiac stress test should be considered if the patient reports poor exercise tolerance or if cardiac symptoms are present. Other indications for a preoperative cardiac evaluation include a history of prior myocardial infarction, known or suspected heart failure, cerebrovascular disease, insulindependent diabetes, and serum creatinine >2.0 mg/dL.
Preoperative chest x-ray and pulmonary function tests do not predict postoperative pulmonary complications and therefore should not be routinely ordered before surgery. A thorough clinical assessment will detect most high-risk conditions. Women with dyspnea, poor exercise tolerance, or unexplained cough should be considered for further evaluation.
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