Gustavo Rodriguez

Preoperative medicine is not “medical clearance”: it is risk modification Surgery challenges physiological reserve. Anesthetic-induced vasodilation, blood loss, fluid shifts, inflammation and postoperative immobility can expose cardiovascular, respiratory or metabolic vulnerabilities that remain compensated in daily life. The question before surgery is not simply whether a patient is “fit,” but which risks are modifiable and which outcomes matter to the patient. In this review, Irizarry-Alvarado and colleagues challenge the ritual of preoperative clearance. They advocate a stepwise assessment anchored in symptoms, comorbid disease, medications, procedural risk and shared decision-making. More testing does not necessarily mean safer surgery. Routine laboratory panels, electrocardiography, chest radiography and ischemia testing in stable, low-risk patients can generate incidental findings, delays and downstream procedures without changing management. New exertional dyspnea, decompensated heart failure, significant valvular disease or declining exercise tolerance, by contrast, demand focused evaluation because they may signal inadequate reserve. Medication reconciliation is an intervention, not clerical work. SGLT2 inhibitors may increase perioperative ketoacidosis risk during fasting, anticoagulant interruption requires balancing bleeding against thrombosis, and GLP-1 receptor agonists prompt individualized aspiration-risk assessment. These decisions must account for the procedure and the patient rather than follow automatic rules. Importantly, frailty and baseline cognition can predict vulnerability that age alone misses. Functional decline, delirium and loss of independence may matter as much as traditional cardiopulmonary complications. Prehabilitation, nutrition, anemia management and postoperative support should enter the discussion before the operating room. This is a guideline-informed narrative review, not a trial demonstrating that any single assessment strategy improves survival. Its value is a change in clinical reasoning: avoid low-value rituals, identify actionable physiology and coordinate care. A useful preoperative consultation does not certify the absence of risk. It turns recognized risk into a plan. Reference 📚 Irizarry-Alvarado et al. 2026. JAMA Internal Medicine. doi.org/10.1001/jamainternme… #PerioperativeMedicine #Anesthesiology #PatientSafety #ClinicalReasoning #EvidenceBasedMedicine