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  • Establish relationship
  • Familiarize self with patient, their medical problems and need for further evaluation, and the planned surgical procedure
  • Assess anesthetic risk and develop perioperative plan (preoperative medications, intraoperative management, postoperative care)
  • Discuss pertinent anesthetic risks, answer questions, and obtain informed consent
  • Document the above

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Should be done as early as possible before the day of surgery for high-risk patients.

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Institutional differences in requirements and role of preoperative anesthesia evaluation clinics.

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  • Past medical history:
    • Disease processes, symptoms, treatment, severity
    • Degree of optimization
    • Need for further consultation/testing
    • ASA classification correlates well with outcomes
  • Past surgical history
  • Past anesthetic history: general, MAC, spinal, epidural, peripheral nerve blocks
  • Past history of anesthetic complications: allergic reactions, severe postoperative nausea and vomiting, delayed awakening, prolonged paralysis, neuropathy, intraoperative awareness, hoarseness, difficult intubation, postdural puncture headache
  • Family history of anesthetic complications: malignant hyperthermia, prolonged paralysis
  • Current medications:
    • Updated list and what patient took/to take day of surgery
    • Implications regarding intraoperative hemodynamics, drug interactions, tolerance to anesthetic drugs, bleeding tendencies, electrolyte abnormalities
    • See below for role of beta-blockers
    • Herbs or supplements, while not considered medications, can have significant side effects or drug interactions and the patient must be asked about their use (see Chapter 10)
  • Allergies:
    • Allergy versus adverse effects
    • Medications, latex (associated risk factors: see Chapter 35), adhesives, egg, soy

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ASA Physical Status Classification System
INormal, healthy patient
IIMild systemic disease without functional limitations
IIISystemic disease with functional limitations
IVSevere systemic disease that is constant threat to life
VMoribund patient who will not survive without surgery
VIBrain-dead patient for organ retrieval
EAll emergency procedures
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  • Neuro:
    • Seizures, strokes and residual symptoms, TIA, other neurological disease
    • Paresthesias, preexisting neuropathies
    • Cervical spine disease
  • Pulmonary:
    • Asthma (obtain peak flow), emphysema, dyspnea/orthopnea
    • Exercise tolerance and whether due to pulmonary etiology
    • Aggressive preoperative interventions may benefit patients with COPD: bronchodilators, physical therapy, incentive spirometers, smoking cessation, corticosteroids
    • Regional versus general anesthesia in patients at high risk for pulmonary complications
  • OSA:
    • See Chapter 13 for STOP-BANG score if patient suspect for OSA but not diagnosed
    • Presence and severity
    • Use of CPAP/BIPAP and settings
  • Cardiovascular:
    • Angina, CAD, past MI, CHF, valvular disease, arrhythmias
    • Pacemaker/AICD
    • Exercise tolerance and whether functional capacity limited by cardiac causes.
    • Percutaneous coronary intervention (PCI), stents: see Chapter 22
    • Revised Cardiac Risk Index and risk factors associated with perioperative cardiac events (high-risk surgery, ischemic heart disease, congestive heart failure, cerebrovascular disease, diabetes mellitus requiring insulin, preoperative serum creatinine >2.0 mg/dL) predict moderate (7%) to high (11%) risk of major cardiac complications for patients with two to three variables
    • ACC/AHA Task Force 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: see Chapter 7
    • Beta-blockers per 2009 ACCF/AHA focused update on perioperative beta-blockade:
      • Continue chronic beta-blocker therapy
      • Initiation recommended in patients undergoing vascular surgery with high cardiac risk (CAD, ischemia on preoperative testing)
      • ...

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