In evaluating the cardiovascular system , the main objective should be to decide whether a patient needs further cardiac testing (stress test) or intervention (cardiac catheterization or cardiac surgery) prior to elective surgery.

Patients should be asked about any history of shortness of breath, dyspnea, chest pain, chest tightness, edema, hypertension, myocardial infarction, cardiac surgery, use of anticoagulants, diuretics, antihypertensive medication, use of antibiotics before dental work, last echocardiogram, or stress test.

One should then determine a patient’s functional capacity (see table below). Studies have correlated better perioperative outcome with patients whose metabolic equivalent (MET) activity was greater than or equal to 4 METs (see Table 8.1).

The revised ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation & Care for Noncardiac Surgery recommend the following stepwise approach to evaluating a patient’s cardiac status for patients undergoing noncardiac surgery:

Postoperative pulmonary complications may prolong the patient’s hospital stay by an average of 1–2 weeks. Therefore, it is important to review patient and procedure-related risk factors, perform a clinical evaluation, and recommend risk-reduction strategies to improve patient care and outcome (Table 8.2).

Potential patient-related risk factors for perioperative pulmonary complications include:

Potential procedure-related risk factors include:

Clinical evaluation should encompass a thorough history (i.e., inquiring about shortness of breath, wheezing, chest pain, recent fever/chills, bronchitis, asthma, emphysema, history of pneumonia or lung surgery, use of steroids) and a physical exam (i.e., auscultation for decreased breath sounds, wheezes, rhonchi, prolonged expiratory phase). Once all of the information is gathered, risk-reduction strategies (Table 8.3) can be implemented to optimize patient care.

Hepatic disease can contribute to end-organ dysfunction (endocrine system, pulmonary edema, pulmonary hypertension, renal failure, and cardiomyopathy) and increase the risk during certain surgeries. Hepatic disease can also cause abnormal coagulation and altered drug pharmacokinetics.

Gastrointestinal diseases may increase the potential for aspiration, dehydration, electrolyte disturbances, and anemia. While screening for gastrointestinal disease, it is important to inquire about history of nausea, vomiting, heartburn, food regurgitation, diarrhea, bloody stools, hiatal hernia, gastric ulcers, viral hepatitis, and alcoholism.

Bleeding disorders may increase the risk of perioperative complications, and necessitate further preoperative evaluation and planning. Possible causes of bleeding may be due to disorders of coagulation factors (e.g., hemophilia, Von Willebrand’s disease), thrombocytopenia, leukemia, platelet disorders (e.g., Bernard–Soulier syndrome, uremia), certain medications (e.g., warfarin, heparin, clopidrogel), cancer, and liver disease.

Endocrinopathies may carry a high risk for morbidity and mortality. Patients should be assessed for any history of risk factors for diabetes mellitus.

Perioperative mortality associated with pheochromocytoma and carcinoid syndrome can reach 50 % if undiagnosed. Thus, screening patients for any history of thyroid, parathyroid, adrenal, or pituitary disease, and carcinoid syndrome, may help reduce potential perioperative risks.

History of any kidney disorder holds importance during the preoperative evaluation since abnormal renal function may result in secondary physiologic imbalances, abnormal platelet function (impaired aggregation), anemia, electrolyte imbalances, peripheral neuropathies, and altered drug metabolism and excretion. Investigation of a patient’s history of renal insufficiency, renal failure, and dialysis dependence (including timing and frequency) should therefore be undertaken.

When screening a patient for neurologic disease , the anesthesiologist should elicit a history of seizures, convulsions, tremors, headaches, numbness or tingling of an extremity, nerve injuries, and multiple sclerosis. Performance of a neuraxial technique or a regional nerve block requires knowledge of any previous nerve injuries or deficits (and documentation if present).

One should ascertain any history of low back pain, radicular pain, herniated disks and chronic pain managed with opioids. Patients should also be assessed for any history or signs of myopathies – as they may portend postoperative muscle weakness.

A preoperative physical exam begins with noting the patient’s baseline vital signs. During the airway evaluation, first document the Mallampati score (see Chap. 9, Airway Evaluation and Management). Then be sure to note any gross external features such as facial trauma, prominent incisors, a beard or moustache, a large tongue, neck masses, tracheal deviation, or if the patient is edentulous – all factors which could contribute to difficult mask ventilation or intubation. Note any possible airway obstruction (i.e., peritonsillar abscess, trauma) and limited neck mobility. The cardiopulmonary exam includes assessment of rate and rhythm, murmurs, wheezing, rhonchi, stridor (inspiratory versus expiratory), peripheral pulses, and baseline pulse oximetry saturation. Gastrointestinal exam includes looking for signs of ascites, abdominal distension, and guarding. Musculoskeletal exam may include neck range of motion, scoliosis, and assessment of pectus excavatum/carinatum. Finally, a neurologic exam may include an assessment of baseline muscle strength, mental status and any signs of preexisting nerve injury.

The generic name of all medications with the route, dosage, and timing (including time of last dose) should be noted. In some cases, it is helpful to include the length of time the patient has been taking a given medication – particularly opioids as chronic use may lead to higher perioperative opioid requirements. Additionally, long-term use of steroids may result in adrenal insufficiency and steroid supplementation during surgery may be indicated.

A medication history should also encompass any over-the-counter or alternative medicines (i.e., herbal medications). This is important because many supplements have clinically important side effects that may manifest during anesthesia (e.g., ginko and garlic both potentiate anticoagulant medications, St. John’s Wort can prolong anesthesia, and Ephedra may cause dysrhythmias).