1.1 Preoperative Evaluation

BobbieJean Sweitzer

Inadequate preoperative evaluation and optimization are linked to perioperative mortality and morbidity (1,2). Health care is increasingly fragmented, medical records are not always available, and relevant information may be difficult to access. Communication failures and misunderstandings underpin many of the reported incidents. Preoperative evaluation can improve outcomes, and reduce mortality and morbidity (2,3).

Goals of preoperative evaluation include:

  • Identification of comorbid conditions

  • Documentation of current medications

  • Clarification of allergies

  • Elucidation of previous complications of anesthesia

  • Management and optimization of medical diseases

  • Assessment of perioperative risk

  • Education of patients and families

  • Procurement of informed consent

  • Interventions to lower risk (smoking cessation, preventive care)

  • Assessment of appropriateness for ambulatory or remote locations

  • Arrangement for special anesthetic techniques

  • Development of postoperative care plans

  • Instructions for medication management and fasting

  • Completion of regulatory requirements

Preoperative evaluation is a necessary and required component of perioperative care for all patients. However, not all patients will benefit from the same approach and matching resources to benefits is desired. Appropriate timing of the preoperative evaluation considers comorbidities, access to healthcare records, other provider relationships, and the urgency of the procedure. Some individuals will require evaluation, testing, interventions to improve health status, and intensive planning and coordination of care. These patients benefit from assessment in advance of procedures (Table 1.1). Healthy patients having low-risk procedures can be seen on the day of their procedure immediately before anesthesia. Patients with co-existing conditions or advancing age are at increased risk (4). The invasive nature and extent of surgery are associated with risk.

A mechanism to obtain information about the patient and triage guidelines can determine which needs to be evaluated ahead of time (Table 1.2). The important

components of the patient history are shown in Figure 1.1. This information is best obtained as soon as surgery is being considered. The form can be completed by the patient in person (paper or electronic version), remotely via electronic health record portals, web-based programs, or during a telephone interview. The information is used to complete the medical history and to triage services. Bolded items in Figure 1.1 indicate medical conditions which are associated with higher risk and/or may require further testing and optimization. Gathering information and effectively triaging patients for preanesthetic assessments and ensuring adequate evaluation and optimization increases patient satisfaction, lowers risk, and improves operating room efficiency and resource utilization (5). In addition, perioperative medicine clinics provide opportunities for behavioral modification intervention at a “teachable moment” when patients may be more receptive to change (6).

TABLE 1.1 Criteria Prompting Preoperative Evaluation Ahead of the Day of Surgery/Procedure

Anesthesia related

 Previous difficult intubation

 Allergy to succinylcholine

 Malignant hyperthermia

 Pseudocholinesterase deficiency

 Paralysis or nerve damage during anesthesia



 Adrenal disorders


 Hypothyroidism, inadequately treated

 Symptomatic goiter


 Normal activity inhibited

 Medical assistance at home within 2 months

 Hospital admission within 2 months

 Obesity; BMI >40

 Age >75 years, unless surgery is minor (cataract, cystoscopy) and under monitored anesthesia care

 Patient or guardian cannot hear, speak, or understand English


 Seizure disorder

CNS disease (e.g., multiple sclerosis)


 Myasthenia gravis

 Muscular dystrophy


 Active disease


 Liver transplant


 Unusual anatomy

 Tumor or obstruction


 Chronic kidney disease



 Coronary artery disease

 Atrial fibrillation

 Poorly controlled hypertension

 Systolic BP >180 mm Hg

 Diastolic BP >110 mm Hg

 Heart failure



 Heart transplant


 Kyphosis or scoliosis compromising function

 Cervical or thoracic spine injury/disease


 Chemo- or radiotherapy within 2 months

 Significant compromise


 Asthma or COPD, severe or poorly controlled or exacerbation within 1 month

 Ventilatory assistance

 Lung transplant


 Pregnant (unless the procedure is termination)


 Blood transfusion likely

vICU admission planned

 High-risk surgery

BMI, body mass index; BP, blood pressure; CIED, cardiovascular implantable electronic devices; LVAD, left ventricular assist devices; COPD, chronic obstructive pulmonary disease; CNS, central nervous system; ICU, intensive care unit

TABLE 1.2 Triage Guidelines

Patients for low-risk procedures typically done with sedation

  • In-person evaluation well before the day of surgery is recommended for patients with any one of the conditions from list 1.

Patients for moderate-high-risk procedures

  • In-person evaluation well before the day of surgery is recommended for patients with any one of the conditions from list 1 or list 2.

List 1

  1. Poor historians who do not know their medications or medical history

  2. Unable to lie flat and still for the duration of the procedure

  3. Obstructive sleep apnea without treatment

  4. BMI >40

  5. Heart failure

  6. Pacemaker or implantable cardiac defibrillator

  7. Hospitalization for medical problems within the last 2 months

  8. Unable to perform activities of daily living (feeding or dressing oneself)

  9. Myocardial infarction within the last 60 days

  10. Coronary stents within the last 6 months

  11. Stroke or TIA within the last 3 months

  12. Use of anticoagulants if these must be stopped for the procedure

  13. Oxygen use

  14. Previous serious problems with anesthesia such as malignant hyperthermia, nerve damage

  15. Dialysis patient

  16. Severe liver disease

  17. Cannot hear, speak, or understand English

  18. Significant dementia or cognitive impairment

  19. Pregnancy (unless procedure is a termination)

  20. Obviously difficult airway or history of same

  21. Poorly controlled hypertension (SBP >180; DBP >110)

  22. Poorly controlled seizure disorder

  23. Pulmonary hypertension

  24. Significant airway abnormalities (goiter, tumors, tracheostomy)

List 2

  1. Age >75 years

  2. Taking >8 prescription medications

  3. Heart disease of any type

  4. Medical condition inhibiting normal daily activity

  5. Inability to climb 1 flight of stairs

  6. Conditions necessitating assistance or monitoring at home within last 2 months

  7. Diabetes mellitus

  8. Chronic pain

  9. Kidney disease

  10. Liver disease

  11. Significant lung disease (use of daily medications)

  12. Likely to require a blood transfusion

  13. Patient refusing blood transfusion

  14. Planned postoperative ICU admission

  15. Previous transplant

  16. Significant spine disease (e.g., scoliosis or neurologic symptoms)

  17. Rheumatoid arthritis

  18. Chemotherapy or radiation therapy within the previous 2 months

  19. Active cancer

  20. Thyroid disease

  21. Adrenal disease

  22. Neurologic disease (seizure, paralysis)

  23. Chronic obstructive lung disease

  24. Muscular dystrophies

The American Society of Anesthesiologists recommends at a minimum that the preanesthetic assessment includes the following (7):

  • Patient interview

  • Focused examination of the airway, lungs, and heart

  • Review of pertinent medical records

  • Indicated preoperative tests

  • Consultations with specialists as needed

The history and physical examination, commonly referred to as the clinical examination, is the basis for establishing diagnoses and eliminating alternative hypotheses. The history alone provides 56% of correct diagnoses in a general medical clinic and adding the physical examination increases this to 73% (8). In patients with cardiovascular (CV) disease, the history establishes the diagnosis two-thirds of the time, and the physical examination contributes 25% (8). Diagnostic tests, such as chest radiographs and electrocardiograms (ECGs), helped with only 3% of diagnoses, and special tests (e.g., stress testing) assisted with 6%. The history is the most important component in diagnosing respiratory, urinary, and neurologic conditions. The patient history rather than abnormal tests predict perioperative outcomes (9). Tests should

only confirm what is already suspected by the clinical examination. The diagnostic acumen of clinicians results from the ability to integrate information gained during the clinical examination. Listening to and examining patients and assimilating their stories and outcomes of their illnesses lead to pattern recognition. Obtaining the patient’s history is not simply asking questions but asking the right questions, often in a variety of ways, and interpreting and carefully recording the answers. Rather than simply compiling facts. Providers need to develop an overall impression as the interview progresses to efficiently evaluate patients and develop next steps. Complete and thorough histories assist in planning appropriate and safe anesthesia care and are more accurate and cost-effective in establishing diagnoses than screening tests (9).

Figure 1.1 (Continued)

Figure 1.1 (Continued)

The classic “history of present illness or HPI” as it relates to the anesthesia evaluation starts with the planned procedure and the underlying reason for surgery. How the surgical condition developed, associated complications, and prior therapies are important. A complete listing of current and past medical conditions with delineation of severity and treatments are essential. Simply noting diseases such as hypertension or coronary artery disease (CAD) or symptoms like shortness of breath or chest pain is not sufficient. One must explore the severity and the stability of the conditions, current or recent exacerbations, and prior treatments or planned interventions. Any activity-limiting nature of a condition is equally important. One notes previous surgical procedures, especially those on major organs, the spine and joints. The patient’s medical problems, previous surgeries, and responses to questions will elicit further inquiry to establish a complete history.

Previous experiences with anesthesia, including types of anesthetics are elucidated. Anesthesia-related complications are noted. A personal or family history of malignant hyperthermia (MH) or pseudocholinesterase deficiency is documented (see Chapters 16.5 and 16.6). A history of difficult airway management is important (see Chapter 16.3). Obtaining records from previous anesthetics may clarify ambiguities and can assist with planning a safe anesthetic.

A determination of the patient’s cardiorespiratory fitness or functional capacity is useful in guiding additional preanesthetic evaluation and predicting outcomes and perioperative complications. Defining exercise limits may be the single best predictor of overall perioperative risk. The easiest and most common approach is simply asking the patient to name the most strenuous activity they do regularly or have done most recently. Limiting symptomatology such as chest pain, dyspnea, or claudication should prompt further investigation. Ascertaining if patients can achieve at least an average functional capacity defined as a metabolic equivalent (MET) of 4 by walking up a flight of stairs (at least 11 to 12 steps) predicts better outcomes (10,11).

Prescription and over-the-counter medications, including supplements and herbals, along with dosages and schedules are carefully recorded. Determining allergies to medicines and substances such as latex or radiographic dye with special emphasis on the specifics of the patient’s reaction to the exposure are necessary (Chapter 13.1). Use of tobacco, alcohol, or illicit drugs is documented. Tobacco exposure using packyears (number of packs of cigarettes smoked/day × number of years of smoking) is best. For example, two packs of cigarettes daily for 10 years is recorded as 20 packyears of tobacco use.

A screening review of systems (ROS) is especially useful to uncover symptoms that may lead to establishment of previously undiagnosed conditions. A ROS is not a listing of medical diagnoses; those belong in the problem list or medical history sections. A general appraisal of all organ systems is ideal. For example, asking patients if they have ever had problems with their heart, lungs, kidneys, liver, nervous system, or if they have had cancer, anemia, bleeding problems, or ever been hospitalized for any reason will often prompt recall of medical problems or symptoms. A preoperative ROS (Table 1.3) places special emphasis on airway symptomatology, CV, pulmonary, hepatic, renal, endocrine, or neurologic symptoms. One inquires about chest discomfort (pain, pressure, tightness), duration of discomfort, precipitating factors, associated symptoms, and methodologies

of relief. Shortness of breath, with exertion or when lying flat (orthopnea), and peripheral edema are important to elicit. Patients are asked about a history of heart murmurs and what diagnostic studies have been done to evaluate a murmur. Identifying risk factors for heart disease including a family history of cardiac disease, hyperlipidemia, tobacco abuse, diabetes, and kidney or other vascular disease determines how one approaches further risk assessment. A history of heartburn, especially with associated reflux or after a period of fasting comparable to that which will occur preoperatively, is important. A personal or family history of bleeding after surgery or after tooth extraction, need for transfusion, a history of liver disease, or Ashkenazi Jewish lineage can suggest a bleeding disorder (see Chapters 9.7, 9.8, 9.9 and 9.10) (12). Women of child-bearing age are prompted to recall their last normal menstrual period and their likelihood of being pregnant. This history is more reliable if the female patient, especially a minor child, is interviewed in privacy. Questioning the patient about snoring and daytime somnolence may suggest undiagnosed sleep apnea (see Chapter 4.8).

TABLE 1.3 Review of Systems (ROS)

Constitutional Symptoms

□ Unexplained weight loss

□ Night sweats

□ Fatigue

□ Fever

□ Recent trauma

□ Unexplained falls


□ Heart burn

 □ With certain foods

 □ After fasting all night

□ Abdominal pain

□ Difficulty swallowing

 □ Solids

 □ Liquids

□ Nausea

□ Vomiting

□ Diarrhea


□ Visual changes

□ Eye pain

□ Itchy/teary eyes

□ Double vision

Ears, Nose, Mouth, and Throat (ENT)

□ Runny nose

□ Frequent nose bleeds

□ Gingival bleeding

□ Sore throat


□ Dysuria

□ Last menstrual period (for women of child-bearing age)


□ Chest pain

 □ With exertion

 □ At rest

□ Shortness of breath

□ Exercise tolerance

 □ Good (>4 METs)

 □ Poor (<4 METs)

□ Paroxysmal nocturnal dyspnea

□ Orthopnea

□ Edema

□ Palpitations

□ Loss of consciousness


□ Anemia

□ Prolonged or excessive bleeding after dental extraction

□ Bleeding after injury or surgery

□ Family history of bleeding disorders

□ History of a blood transfusion

□ History of blood clots


□ Cough

□ Sputum production

□ Wheeze

□ Hemoptysis

□ Shortness of breath

□ Recent URI

 □ Resolved


□ Changes in sight, smell, hearing

□ Loss of consciousness

□ New headache

□ Paresthesia

□ Numbness

□ Limb weakness

□ Falls

□ Vertigo

□ Speech problems

□ Tremor

□ Dizziness


□ Pain

□ Joint swelling

□ Decreased range of motion


□ Diaphoresis

□ Weight loss despite increased appetite

□ Fatigue

□ Polydipsia

□ Polyuria

Establishing a patient’s ability to care for themselves and engage in activities of daily living ADLs (bathing, feeding, dressing) are important. An evaluation of cognition using the Mini-Cog (see Chapter 5.13) and a formal assessment of frailty are important in elderly patients. Asking about appetite and weight loss, especially unintended loss of 10 pounds or 10% of body mass are the basis of nutritional assessment. Finally, a review of records, including notes from primary care physicians, specialists, or the hospital, and test results is important.

Nov 14, 2018 | Posted by in ANESTHESIA | Comments Off on Overview

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