Pre-operative medical clearance in Philadelphia is required for most elective surgeries. The substantive part is a focused history, exam, and risk-appropriate testing (EKG for older patients, labs as indicated by patient factors). Most healthy adults under 65 with no significant comorbidities need only a basic workup; patients with cardiovascular disease, diabetes, or other significant conditions need more thorough evaluation. Fishtown Medicine offers same-week pre-op clearance for members and coordinates with the surgical team.
Pre-op clearance can be simple when done correctly. It is a focused evaluation of fitness for anesthesia and surgery, not a comprehensive overhaul of every health issue. The substantive work is risk assessment plus testing only when indicated.
What pre-op clearance actually covers
The substantive elements:
- Focused history. Cardiovascular and pulmonary status, prior anesthesia issues, current medications, allergies, bleeding history, recent infections, functional capacity.
- Focused physical exam. Cardiopulmonary, airway assessment, exam of relevant systems.
- Risk stratification by validated tools (Revised Cardiac Risk Index for cardiac risk in non-cardiac surgery).
- Indicated testing only. Pre-op routine labs and EKG on every patient are not evidence-based; testing should be indicated by patient factors and surgery type.
- Medication management. Anticoagulants, antiplatelets, diabetes medications, sometimes steroids. Coordination with surgical team on timing.
- Optimization recommendations. Smoking cessation, glycemic optimization, blood pressure control, anemia correction as appropriate.
What testing is actually needed
The 2014 ACC/AHA guidelines and updated 2024 guidance:
- EKG for patients with cardiovascular disease, structural cardiac disease, arrhythmia history, or intermediate-to-high risk surgery, particularly over 65. Not routine for asymptomatic younger adults.
- CBC for major surgery or patients at risk of anemia.
- Basic metabolic panel for patients on diuretics, with kidney disease, or for major surgery.
- Coagulation studies for patients on anticoagulation, with bleeding history, or for major surgery.
- Type and screen or crossmatch for surgeries with bleeding risk.
- Chest X-ray is rarely indicated routinely.
- Stress testing for patients with active cardiac symptoms or specific high-risk features.
Routine testing on every patient drives up cost without changing outcomes.
Cardiovascular risk assessment
For non-cardiac surgery, the Revised Cardiac Risk Index (RCRI) stratifies risk:
- History of ischemic heart disease.
- History of congestive heart failure.
- History of cerebrovascular disease.
- Diabetes requiring insulin.
- Creatinine over 2.0.
- High-risk surgery type.
Patients with 0-1 factors and good functional capacity usually need no further cardiac workup. Patients with 2+ factors or unable to climb a flight of stairs may need additional evaluation.
Medication management
Common scenarios:
- Anticoagulants (warfarin, DOACs): timing of discontinuation and bridging depend on indication and surgery bleeding risk. Coordinate with surgical team.
- Antiplatelets (aspirin, clopidogrel): continuation vs. interruption depends on indication (recent stent vs. primary prevention) and surgery type.
- GLP-1 medications: hold the day of surgery; longer holds may be appropriate for some procedures based on emerging guidance.
- Diabetes medications: continue most oral agents until surgery; adjust insulin per guidance.
- Blood pressure medications: continue most, though ACE inhibitors and ARBs are sometimes held the day of surgery.
- Steroids: stress-dose coverage for patients on chronic steroids.
- Estrogen and testosterone: continuation usually fine unless major surgery with thrombotic risk.
Fishtown Medicine
A 90-minute conversation with Dr. Ash. A written plan you can actually follow.
How pre-op clearance works at Fishtown Medicine
For members, message to schedule pre-op clearance. We aim for same-week appointments. The visit covers history, exam, indicated testing orders, medication management, and documentation for the surgical team.
We coordinate with the surgical team and anesthesiologist when complex.
What it costs
Membership covers all visits and ongoing management; see pricing for current rates. Pre-op clearance is included. Labs and EKG are billed separately, usually through insurance.
For non-members, pre-op clearance can be done as a one-time visit; pay-what-you-can urgent care is available.
Key Takeaways
- Pre-op clearance is a focused medical evaluation, not a comprehensive workup.
- Testing should be indicated by patient factors, not routine.
- Medication management and risk stratification are the substantive work.
- Fishtown Medicine offers same-week pre-op clearance for members.
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