- 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
Should be done as early as possible before the day of surgery for high-risk patients.
Institutional differences in requirements and role of preoperative anesthesia evaluation clinics.
- 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)
- Allergy versus adverse effects
- Medications, latex (associated risk factors: see Chapter 35), adhesives, egg, soy
ASA Physical Status Classification System
|I||Normal, healthy patient|
|II||Mild systemic disease without functional limitations|
|III||Systemic disease with functional limitations|
|IV||Severe systemic disease that is constant threat to life|
|V||Moribund patient who will not survive without surgery|
|VI||Brain-dead patient for organ retrieval|
|E||All emergency procedures|
- Seizures, strokes and residual symptoms, TIA, other neurological disease
- Paresthesias, preexisting neuropathies
- Cervical spine disease
- 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
- See Chapter 13 for STOP-BANG score if patient suspect for OSA but not diagnosed
- Presence and severity
- Use of CPAP/BIPAP and settings
- Angina, CAD, past MI, CHF, valvular disease, arrhythmias
- 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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