The Preoperative Evaluation

Key Points to Start:

*Remember, you can access Epic through the Ether website (ether.stanford.edu) whether on or off campus*

*If there is no Pre-op done in Epic, do a chart biopsy, look up old records, and call the patient (if necessary) to gather this important information that is vital in developing a safe and effective anesthetic plan*

*One question to always keep in mind while completing your pre-op: Is this patient optimized for surgery?*

Preop Templates

Check out these very cool preop template forms designed by Dr. Jared Pearson. I highly recommend you use them to notate your H&P and anesthetic plan for your cases.
[Download PDF Version] [Download Word Document Version]

Dr. Chu and Dr. Harrison talk about and simulate the Preoperative Evaluation from March START podcast

 

Identifying Statement

- Name, age, sex, planned surgery and indication for procedure, surgeon

Past Medical History:

Remember to list all known medical history with specific emphasis on the following:

• Cardiovascular:
  •  Hypertension (baseline blood pressures, what medications, any complications)
  •  Coronary artery disease (hx of MI, stents/CABG hx, recent functional studies (stress testing, cath reports, echos)
  • Arrhythmias (what medications used, any implanted devices, recent symptoms, Holter tests, etc)
• Pulmonary:
  • COPD: (Medications used, frequency of exacerbations, steroid use, onhome oxygen, recent infections, any recent PFT information, recent CXR data ifapplicable)
  • Asthma (Medications used, frequency of exacerbations, ever been intubated, steroid use)
  • Smoking history (Pack year history, recent episodes of bronchitis, sputum production)
  • Sleep apnea (may be a predictor of difficult airway)
• Gastrointestinal:
  • GERD (Medications used, degree and frequency of symptoms)
  • Inflammatory bowel disease (Steroids/immunomodulators used)
  • History of post-operative nausea or vomiting
• Endocrine:
  • Diabetes Mellitus (Type I vs II, medications used, home fingerstick readings, last Hgb A1C, any known macro/microvascular complications)
  • Thyroid disorders
  • Adrenal insufficiency
• Heme
  • History of bleeding disorders, blood clots
  • Is the patient on anticogulation medications? List any recent pertinent coagulation studies, if/when anticoagulation was reversed
• Neurological
  • List any deficits including residual effects of old CVAs
• Rheumatological
  • History of steroid use, lung/systemic involvement, any known joint (ie. atlanto-axial) instability
  • **Looking at an old anesthetic record is crucial to see if there were any airway difficulties in patients with RA!**
• Pain
  • Note preoperative pain score and document any history of chronic pain and list all preoperative pain medications and dosages taken by the patient (chronic opiate users may require more intra-operatively)
• Other
  • List all other medical conditions

 

Review of Systems: Remember to be systematic and complete, with particular focus on the following:

• Constitutional: recent fevers or infections, nighttime sweating, motion sickness symptoms
• Cardiovascular: Exercise tolerance (how many stairs?), angina, activity level

 

• Pulmonary: Shortness of breath, cough, dyspnea on exertion, smoker, use of inhalers, baseline oxygen if applicable
• Gastrointestinal: Reflux symptoms, NPO status

 How long should your patient fast?

Solid food, milk, infant formula	6 hours
Breast milk	4 hours
Clear liquids (ie water, soda, juices, black coffee)	2 hours

 

  

• Heme: Easy bruising or bleeding
• Musculoskeletal: Any cervical motion instability, myalgias, range of motion of extremities

 

Past Surgical History

• Past surgeries and their indications, any complications, where surgeries were performed (if known)
• Any implications for your plan? (ie cervical fusion surgery may impede normal intubation positioning)

 

Past Anesthetic History

• Prior history of adverse reactions to anesthesia, problems with airway management, difficult IV access, prolonged emergence, post-operative nausea/vomiting

  

Risk Factors for Developing PONV 

Procedure risks	Patient risks	Medication risks
Laproscopic surgery	Female	Opioids
Surgery on genitalia	Non-smoker	Volatile inhalation agents
Craniotomies	Prior PONV history	Nitrous oxide
Shoulder surgery	History of motion sickness	Neostigmine
Middle ear surgery	Young age
Eye muscle surgery

 

Family History

• History of malignant hyperthermia, pseudocholinesterase deficiency, or any other adverse reactions

 

Social History

• Alcohol use: How frequent, last drink, any complications from use
• Tobacco use: Duration in pack years, when patient last smoked
• Illicit drug use: Past or present use, when patient last used
• **Consider urine toxicology screen if clinically indicated to prevent autonomic instability**

 

Medications

• List all medications that the patient is taking, including over the counter and herbal medications.  List the most important drugs first and give doses for important medication
• Especially medications for hypertension, diabetes, opiate pain medications, and blood thinners!

 

Allergies

• List all allergies, especially latex and antibiotics, and reactions to each allergen if known.

 

Preoperative Physical Examination

• Weight and height, vitals including room air saturation, and general appearance
• Airway: Includes Mallampati score, thyromental distance, cervical motion

 

Mallampati Scoring

Grade of View	Structures Visualized
1	Tonsillar pillars, soft palate, entire uvula
2	Tonsillar pillars, soft palate, part of uvula
3	Soft palate, base of uvula
4	Hard palate only, no uvula visualized

 

 

• Cardiovascular: complete exam with a focus on murmurs or rubs, check for bruits
• Respiratory: complete exam with a focus on wheezes or crackles
• Neurologic: complete exam, note any deficits discovered and compare to old records
• Extremities: complete exam, note any clubbing, deformities, bruising, and gauge level of difficulty for IV access

 

Additional Information

 

EKG

• Full interpretation including rate, rhythm, and ST changes. If available, compare to old EKGs to assess changes

Labs

• Review all recent labs and if abnormal results, compare to old values to assess changes

 

Assessment and Developing an Anesthetic Plan

           
ASA Status Classification

1	Healthy patient with no disease states
2	Controlled medical conditions with mild systemic effects and no limitations in functional ability	Controlled hypertension
3	Severe systemic disease with limitations in functional ability	Compensated CHF, stable COPD or angina, chronic renal insufficiency
4	Poorly controlled/Severe systemic disease with significant functional impairment that is a threat to life	Decompensated CHF, uncontrolled COPD, unstable angina
5	Critical condition,  death within 24 hours without surgery	Ruptured AAA
6	Brain dead	Organ donor
E	Emergency	Trauma, GI perforation

 

Dr. Chu and Dr. Harrison model how to construct an anesthetic plan from March START podcast

 

1. Consult the surgery listing to see how the surgeon booked the case—is this anesthetic option appropriate?
2. Search resources in developing your plan

• Jaffe’s Anesthesiologist’s Manual of Surgical Procedures is an excellent pre/intra/post-op reference
• Consult your big sib or other colleagues to discuss your plan and inquire about other options

  

3. Define the type of anesthesia: MAC, GA, TIVA, Regional, etc
4. Note what additional invasive monitors/IV access that will be required

 

Calling your Attending:

 

Dr. Chu and Dr. Harrison model how to call your attending to discuss your pre-ops from March START podcast

 

• You can find your Attending’s contact information here on ether, and click on “dashboard”          
• Send courtesy page if no answer with short message (no patient information!) and callback number

Always come up with your own anesthetic plan before talking the case over, but be open to change and suggestions from your attending!