Occasionally, it is in the best interest of the patient to delay elective surgical procedures for further medical evaluation and optimization. Some conditions can significantly increase morbidity and mortality if not appropriately evaluated and treated.
Recent MI. If the patient has had a recent MI that was managed medically, then elective noncardiac surgery should be delayed for 60 days. If the patient underwent percutaneous coronary intervention, surgery should be delayed in accordance with antiplatelet therapy recommendations. See Chapter 3: Specific Considerations for Cardiac Disease for further details.
New dysrhythmia. New-onset atrial fibrillation, atrial flutter, supraventricular tachycardia, sustained ventricular tachycardia, and second-degree, type II, or third-degree heart block must be evaluated with an ECG, rhythm strip, electrolyte replenishment, and a cardiology consultation. Surgery should be postponed until workup and treatment are complete and stability is established.
Coagulopathy. Coagulopathies can predispose the patient to massive intraoperative blood loss. As such, surgery should be postponed until all possible etiologies have been thoroughly investigated and treated.
Hypoxia. If hypoxia is of unclear etiology, surgery should be postponed until the cause is investigated and the patient optimized. V/Q mismatch, dead space, shunt, decreased fraction of inspired oxygen (FiO2), and inadequate respiratory rate/effort should be considered. Workup should begin with a physical examination and evaluation of vital signs. Diagnostic studies such as a CXR, computed tomography (CT) scan, or arterial blood gas may be ordered as needed.
New cardiovascular symptoms. Unstable angina and new shortness of breath or DOE are concerning symptoms. Surgery should be postponed until they can be fully evaluated by an appropriate specialist. New ECG changes, especially those indicative of silent MI, such as bifascicular block or new Q waves, must be evaluated prior to elective procedures.
New murmurs. New heart murmurs may be indicative of a change in valvular pathology and should be evaluated by echocardiography and/or a cardiologist before proceeding with elective surgery.
Hypertension/hyperglycemia. Many patients present with hypertension due to medication holds or anxiety. Additionally, hyperglycemia is common due to underlying poor control or instruction for reduced doses of insulin while the patient is NPO. In these instances, a discussion with the surgical team is warranted prior to cancellation.