Chapter 6. Overview of Preoperative Assessment and Management

1. Comprehensive preoperative evaluation and management improve patient satisfaction, outcomes, and safety.

2. Inadequate preoperative evaluation and management increase perioperative adverse events and often lead to delays or cancellations of procedures.

3. At a minimum, the preanesthesia visit should include an interview with the patient to review the medical history (including medications, allergies, comorbid conditions, previous operations, and anesthetics), an appropriate physical examination, review of diagnostic data, assignment of an American Society of Anesthesiologists physical status score, and a formulation and discussion with the patient of the anesthetic plan.

4. The medical history is the most important component of preoperative assessment.

5. Findings from the history and physical examination determine the need, if any, for further diagnostic testing.

6. Diagnostic tests should only be ordered if the results will alter the planned anesthetic or procedure or establish an already suspected diagnosis. "Screening" tests are never appropriate.

7. Cardiovascular morbidity and mortality are the leading cause of significant perioperative adverse events.

8. Identification and management of cardiovascular disease is an important goal of preoperative evaluation.

9. Knowledge of risk factors for cardiovascular disease and familiarity with the American College of Cardiology–American Heart Association guidelines for cardiovascular evaluation for noncardiac surgery is essential.

10. A determination of functional capacity or the patient's cardiorespiratory fitness can guide further testing and predict a wide range of complications and outcome.

11. Potentially high-risk patients include those with the following conditions:

    1. Ischemic heart disease

    2. Heart failure

    3. Murmurs

    4. Pacemakers, implantable cardioverter-defibrillators (ICDs)

    5. Vascular stents

    6. Pulmonary disease

    7. Obstructive sleep apnea

    8. Obesity

    9. Diabetes mellitus

    10. Poorly controlled hypertension

    11. Renal disease

    12. Hepatic disease

    13. Substance abuse

    14. Advanced age

    15. Difficult airway

12. Knowledge and management of antiplatelet therapy in patients with coronary stents is imperative in the perioperative period.

13. Poor communication is a common source of medical errors, patient dissatisfaction, and malpractice claims.

14. Practice guidelines can standardize care, decrease delays, and improve outcomes.

15. Anesthesia-directed preoperative evaluation centers can be cost-effective, improve care and safety, and offer services beyond history acquisition, physical examinations, and diagnostic testing.

As the practice of medicine becomes increasingly outcomes driven and cost conscious, clinicians need to reevaluate and streamline methods of patient care. The role of the anesthesiologist as a consultant is more important than ever. No single clinician is better informed and capable than the anesthesiologist to evaluate patients who require anesthesia. Preoperative assessment and management have evolved as the role of the anesthesiologist has expanded outside of the operating theater and as an increasing number of procedures are performed on patients who are not hospitalized before their anesthetics. Reasons for preoperative assessment may entail some or all of the following:

1. To screen for and properly manage comorbid conditions.

2. To assess the risk of anesthesia and surgery and lower it.

3. To identify patients who may require special anesthetic techniques or postoperative care.

4. To establish baseline results for perioperative decisions.

5. To educate patients and families about the objectives and risks of anesthesia and the anesthesiologist's role in perioperative care.

6. To obtain informed consent.

7. To facilitate timely care and avoid cancellations on the ...