Pre-operative Assessment

  • WIPE, blah blah 🙂
  • Confirm correct patient by name and MRN
  • Pt’s demographics: age + gender
  • What surgery the pt is undergoing + diagnosis?

 

– History –

  • Past surgical and anesthetic Hx:
    • Prev surgeries or anesthetics? If yes;
      • Type of anesthesia used? (GA, regional, epidural\spinal)
      • Any complications? (N\V, difficult intubation, malignant hyperthermia, reactions)
  • Past medical Hx:
    • Any chronic diseases? (DM, epilepsy, asthma)
      • If diabetic:
        • Is it controlled? (last reading, HbA1C)
        • Medications? (oral anti-glycemic agents, insulin)
        • End-organ complications? (eyes, kidney, ulcers, neuropathy)
    • CNS: headache, seizures, LOC, increased ICP, prev strokes
    • Neck: thyroid ds, cervical spine trauma, RA
    • CVS: chest pain, SOB (NYHA class), prev MI, dysrhythmia, CHF
    • Resp: cough, asthma, COPD, URTI, sleep apnea (daytime sleepiness, loud snoring, morning headache)
    • Abdomen: N\V, abdo pain, heartburn, liver ds (jaundice), kidney ds (dialysis)
    • GU: dysuria, urinary retention, menstrual hx
    • Hema: anemia (paleness, lightheadedness, palpitations) + sickle cell, coagulopathies (easy bleeding\bruising, VTE)
  • Medication HX:
    • Are you on any medications?
    • Mention that you should discuss w\ the surgeon about specific medications to stop
  • Allergies Hx:
    • Food, medications, anesthetics
  • Family Hx:
    • Difficult intubation
    • Anesthetic reactions
    • VTE\DVT
    • Malignant hyperthermia
    • Pseudocholinesterase deficiency (if yes, ask about type of anesthesia used)
  • Social Hx?
    • Smoking (if yes; stop at least 8 wks pre-op)
    • Last meal

 


– Physical Exam –   

“V-LEMON”

  • Vital Signs
    • HR, RR, BP, O2 sat, BMI
  • Look: “normal face and neck shape, no obvious pathology or syndromic features
    • Chin: receding mandible, beard, obesity “think double-chin :)”
    • Teeth: loose teeth, buck teeth, missing teeth
    • Mucosa: central cyanosis, bleeding, dry mucous membrane
    • Tongue size
  • Evaluate: 3-2-1 (each finger = 2 cm)
    • 3 fingers: thyromental distance (normal < 6 cm)
    • 2 fingers: oral opening (between 2 incisors)
    • 1 finger: anterior jaw subluxation
  • Mallampati score: ask pt to protrude tongue as much as they can
    • Class I: soft palate, uvula, fauces, tonsillar pillars
    • Class II: soft palate, uvula, fauces
    • Class III: soft palate, uvula
    • Class IV: hard palate
  • Obstruction:
    • Stridor
    • Foreign body\abscesses
  • Neck mobility:
    • Full flexion and extension
    • Sniffing position (upper cervical spine extension, lower cervical spine flexion)
    • Sterno-mental distance (normal > 12.5 cm)
  • Mention you should do a focused CNS + CVS + respiratory exam

 

– Investigations –

  • CBC
  • Sickle cell screen
  • Coagulation profile: INR, PTT
  • Electrolytes, liver and renal profile
  • Fasting glucose
  • Pregnancy
  • ECG (if male > 40, female > 50)
  • CXR

 

ASA Classification

Definition Examples
ASA 1 Healthy
ASA 2 Mild controlled systemic disease Obese, OSA, smoker, pregnant, controlled HTN, DM, BS
ASA 3 Moderate – severe uncontrolled systemic disease, limits activity Obese with OSA, COPD, uncontrolled HTN\DM\BS, stable CAD
ASA 4 Life threatening Septic, leaking AAA, epidural hematoma, unstable angina
ASA 5 Moribund pt Late presentation of ischemic limb\angina, rupture AA
ASA 6 Brain dead pt, which organs are to be transplanted

 


– Extra Info –

  • Fasting guidlines:
    • 8 hr -> fatty meal
    • 6 hr -> light meal or infant formula\non-human milk
    • 4 hr -> breast milk
    • 2 hr -> clear fluids
  • When to stop certain meds pre-op?
    • Plavix -> 7 days
    • Aspirin -> no need, unless surgery in closed cavity where you can’t apply pressure if a bleeding occurred (i,e; neurosurgery) -> 5-6 days
    • Heparin -> 6 hours
    • Warfarin -> 5 days -> bridge w\ heparin. (If an emergency case and the pt is already on warfarin w\ high INR -> give 2 units of FFP)
    • DM -> stop metformin 2 d pre-op, if T1DM; give insulin night pre-op
    • ACEI\ARBs -> stop 24 h pre-op
    • Other meds (antihypertensive, thyroid) -> can be taken w\ sips of water while the pt is NPO
    • Smoking -> 8 weeks

 


Download the PDF version: here

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