Pre-op Inpatient Consults
Answer the surgical team’s real question for the inpatient — risk, optimization, and a clear med plan.
Learning Objectives
- 1.Frame the inpatient pre-op consult as risk + optimization.
- 2.Apply the stepwise approach in the inpatient setting.
- 3.Communicate a clear peri-operative medication plan.
Overview
The inpatient pre-op consult answers a specific surgical question: what’s the cardiac risk, what reduces it, and how should the cardiac meds be handled around surgery — without delaying needed operations.
The stepwise approach (inpatient)
- 1.Surgical urgency — emergent surgery proceeds; optimize peri-operatively.
- 2.Screen for active cardiac conditions (ACS, decompensated HF, severe symptomatic valve disease, unstable arrhythmia) → evaluate/stabilize, escalate.
- 3.Estimate cardiac risk (e.g., RCRI) and surgical risk; assess functional capacity.
- 4.Recommend testing only if it will change management.
- 5.Give a clear medication plan and peri-operative recommendations.
Medication management
- •Continue most cardiac meds (e.g., beta-blockers already on); don’t stop abruptly.
- •Anticoagulation/antiplatelet hold-and-restart is case-specific (see Anticoagulation Holds module).
- •Recent stents on DAPT complicate elective timing — coordinate with cardiology.
Answer the question
- •Lead with the answer: proceed/optimize, the risk estimate, and specific recommendations.
- •Avoid the word "cleared"; provide a risk assessment.
Red flags / escalation
- •Active cardiac conditions (recent ACS, decompensated HF, severe symptomatic AS, unstable arrhythmia) → delay elective surgery, evaluate/stabilize, escalate.
Escalate
An active cardiac condition before elective surgery means evaluate/stabilize with the physician — not "cleared." Emergent surgery: optimize and communicate risk rather than delay.
Common beginner mistakes
- •Writing "cleared" instead of a risk assessment.
- •Reflexive low-yield testing that delays surgery.
- •Mishandling anticoagulation/antiplatelet timing.
- •Stopping beta-blockers inappropriately.
Tools
- •RCRI is available under Clinical Tools.
Mini cases
Inpatient consult for "clearance" before urgent hip-fracture repair; the patient has stable CAD and good functional capacity, no active symptoms.
Recommendation?
Show answer
This is urgent surgery with no active cardiac condition and good functional capacity — proceed with risk-based peri-operative recommendations (continue indicated meds, monitor), not additional delaying testing. Provide a risk assessment, not "cleared."
Pre-op consult reveals decompensated heart failure before an elective procedure.
Action?
Show answer
An active cardiac condition — recommend deferring the elective procedure to optimize the HF, and escalate to the physician/surgical team. Don’t "clear" them.