What preoperative assessments are recommended for patients with comorbidities undergoing elective surgery?

For patients with comorbidities undergoing elective surgery, a tailored preoperative assessment is recommended to optimise surgical outcomes and minimise risks. This includes a comprehensive clinical evaluation supplemented by targeted investigations based on the patient's specific comorbid conditions and the planned surgery's complexity.

Cardiovascular assessment should include a resting electrocardiogram (ECG) for all patients with cardiovascular risk factors or symptoms. Resting echocardiography is not routinely recommended but should be considered if the patient has a heart murmur combined with cardiac symptoms such as breathlessness, chest pain, or signs of heart failure, after ECG review and anaesthetist consultation ¹.

Diabetes management requires inclusion of the most recent HbA1c results in the surgical referral. If the patient has diabetes and has not had an HbA1c test in the last 3 months, testing should be offered to optimise glycaemic control preoperatively ¹.

Renal function should be assessed by estimating glomerular filtration rate and measuring electrolytes and creatinine, especially in patients with known renal disease or risk factors, to guide perioperative management ¹.

Respiratory evaluation is generally not routine but may include lung function tests such as spirometry if respiratory comorbidities are present or if the surgery is major and may impact pulmonary function ¹.

Haematological assessment includes a full blood count to detect anaemia or other blood disorders. For patients with iron-deficiency anaemia, preoperative iron supplementation should be considered following NICE guidelines on blood transfusion and iron therapy ¹,².

Urine testing is not routinely recommended unless a urinary tract infection would influence the decision to operate, in which case microscopy and culture of a midstream urine sample should be considered ¹.

Pregnancy testing should be sensitively offered to women of childbearing potential on the day of surgery if pregnancy status is uncertain, with appropriate counselling about risks ¹.

Nutritional screening is advised for patients undergoing intermediate or major/complex surgery to identify malnutrition and guide nutritional support preoperatively ¹,².

Risk stratification tools validated for perioperative risk should supplement clinical assessment to inform shared decision-making and surgical planning ². Lifestyle factors such as smoking and alcohol consumption should be addressed preoperatively to reduce complications ².

Enhanced recovery programmes incorporating preoperative, intraoperative, and postoperative components are recommended for patients undergoing major or complex elective surgery to improve outcomes ².

While UK guidelines do not routinely recommend chest X-rays or sickle cell testing preoperatively, these may be considered based on individual clinical indications ¹.

Recent literature on vascular surgery patients with complex comorbidities, such as those with abdominal aortic aneurysms, supports a multidisciplinary approach to preoperative assessment, emphasising optimisation of cardiovascular status and careful risk stratification to guide timing and type of surgery (Chaikof et al., 2018).