Pre-operative Assessment

Introduction

This page will cover the basics of an anesthetic evaluation

History of Presenting Illness

  • Identify the proposed surgery and approach (e.g. laparoscopic, open, etc.)
  • Identify the key points of their presentation
  • What treatments have been initiated and what has been the response
  • Address the urgency of the case (elective, urgency, emergency)
  • Is the patient NPO (see Pre-operative FastingPre-operative Fasting
    General Guidelines:
    Guidelines have recently changed for fasting. The Canadian Guidelines to the Practice of Anesthesia offer the most current and locally applicable guidelines: 1


    Six hours aft...    )

Past Medical History & Review of Systems

Determine the etiology, severity, treatments, and complications of any medical history

  • CNS
    • strokes
    • seizure
  • Cardiovascular
    • CAD
    • HTN
    • Rhythm issues
    • Valvular issues
    • Functional status (> 4 metabolic equivalents is generally acceptable)
  • Respiratory
    • Smoking history
    • Asthma / COPD
    • Recent infections
    • OSA
  • GI
    • GERD
    • Liver Dysfunction
  • Renal
    • Acute or chronic injury
  • Endocrine
    • Diabetes
    • Thyroid issues
  • Hematologic
    • Problems with bleeding or clotting
    • Contraindications to blood products
  • Spinal deformities
  • Review of systems geared towards uncovering any additional comorbidities
    • Smoking, alcohol use, drug use

Past Anesthetic & Surgical History

  • Review previous anesthetic records if available
  • Review previous airway management (BMV, intubation, LMA)
  • Review previous anesthetic reactions (Post-operative Nausea and VomitingPost-operative Nausea and Vomiting
    General Principles

    Many patients undergoing anesthesia will experience post-operative nausea and vomiting
    Anti-emetic medications are given routinely during anesthesia.
    Combining agents of d...    , Malignant Hyperthermia)

Physical Exam

Airway AssessmentAirway Assessment
Introduction
Every patient coming for anesthesia requires an airway assessment. The goal of the airway assessment is to determine the ease of bag-mask ventilation (BMV), tracheal intubation, LMA pl...

  • Mouth opening, neck ROM, Mallampati score, thyromental distance, jaw prognathism
  • Dentition status, dentures, loose/chipped teeth
  • Facial hair

Cardiac

  • Murmurs, extra heart sounds, JVP, edema
  • Peripheral pulses and IV access

Respiratory

  • Current oxygen requirements
  • Lung sounds

Other Systems

  • Abdominal & neurological examination as needed
  • ease of IV access

Medications

  • Document which medications the patient takes at home and their last dose
  • Look for recent antibiotic administration
  • Always look for antiplatelets and anticoagulants and their most recent dose

Allergies

  • Document any allergies and their reactions

Investigations

Not every patient requires investigations prior to proceeding to the OR, but their historic values can be quite useful.

Labwork:

Look for labwork to further evaluate comorbidities. Some basic labs to review include:

  • Hemoglobin, platelets, white blood cell count
  • INR, PTT
  • Electrolytes, extended electrolytes
  • Renal function
  • BNP, troponin if applicable

ECG:

  • Baseline ECG

Imaging:

Directed at comorbidities

  • Echos and PFTs
  • CT scans, chest x-rays if available

Anesthetic Plan

Synthesize the information above to answer the following questions.

  • What anesthetic options are possible here:
    • General anesthetic with endotracheal tube (Airway Devices#Endotracheal Tube Private or Broken Links
      The page you're looking for is either not available or private!
      )
    • General anesthetic with LMA Airway Devices#Laryngeal Mask Airway Private or Broken Links
      The page you're looking for is either not available or private!
    • Sedation
    • Regional anesthesia +/- sedation
    • Spinal or epidural anesthesia

  • Will this patient tolerate an anesthetic? What therapies can be included to ensure the patient can tolerate the anesthetic plan? (vasopressors, supplemental oxygen, sedation)

  • If the airway is not captured in our plan, would it be easy to secure the airway midway through the case?

  • What is my allowable blood loss? What is this patient's baseline fluid requirement? (Fluid Management in AnesthesiaFluid Management in Anesthesia
    Introduction
    It is helpful to have an idea of how much fluid a patient should receive during an operation. Below are some rules of thumb to calculate the expected needs of a patients. Fluids should...    )

  • What is my analgesic plan for this patient? Pain ManagementPain Management
    Introduction
    Pain management can be a complex topic in anesthesia. Patient factors, like age, comorbidities, and pre-existing chronic pain can help guide analgesia during the operative period. Surg...