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What are the goals of performing a pre-op assessment?

Formulate the most appropriate anesthetic plan
Minimize morbidity and mortality
Evaluate health status- determine if further tests or consults are needed before surgery
Optimize care, satisfaction, and comfort
Minimizing surgical delays or cancellations
Determine post-op disposition
Optimize communications between members of the surgical and anesthetic teams


What are the three main questions answered by the pre-op assessment?

1) Is the patient in optimal health?
2) Can, or should, the patient's mental or physical condition be improved before surgery?
3) Does the patient have any health problems or use any medications that could unexpectedly influence perioperative events?


Previous surgical hx and family hx we are concerned about

MH, atypical acetylcholinesterase, previous anesthetic complications


Medication history we are concerned about

MAOIs, anticoagulants, vaso-active meds, diuretics (may have lyte abnormalities), steroids (we may need to give a stress dose)
Dosing schedule
Supplements/herbals (may interact with meds, alter bleeding, etc)
Substance abuse (smoking, ETOH, illegal drugs)
Allergies (make sure it's an actual allergy!)

We also want to know if they take any OTC meds, and if any of their meds were discontinued for sx and when they were last taken)


What do we want to know about a patient's systemic disease?

Impact on activities
Current and recent exacerbations
Stability (how well has it been controlled)
Treatments and interventions for the disease


Important test for many women to have before surgery

If there is any chance a woman is pregnant, she should have a pregnancy test. Drugs affect the fetus the most during the first trimester, and at this point many women don't know they're pregnant yet.


How long is a typical pre-op assessment

5-15 min


___% of all surgeries are outpatient
___% of all surgeries are in surgeon's offices
___% of all surgeries are AM admissions
___% of all surgeries are on inpatients admitted before the day of surgery



Universal practice guidelines

Are based on current evidence and research
Continuous quality improvement and national patient safety goals
Need to meet CMS and JCo requirements
AANA/ASA standards


Components of the pre-op evaluation

Patient history
Physical Assessment
Lab testing and consultation if needed
Assign an ASA Physical Status Class
Formulate a plan
Discuss the plan with the patient
Informed consent


This information will be listen on the OR schedule

Demographics (Name, age, sex)
Type of anesthesia


What should you confirm with the OR team?

Length of the procedure
Anatomical location and procedure being done
Positioning the OR table and the patient
Need an x-ray?


One of the most important things we should review in inpatient charts

Old anesthetic records


Optimally, when should a pre-op exam take place?

1 week pre-op clinic visit


Why is doing the pre-op clinic visit one week prior to surgery good?

You can do the assessment, and formulate the plan, tell the patient the plan, and get consent out of the way early.
Also, this way the patient has time to complete any pre-op tests or consults prior to surgery


An early pre-op assessment if REQUIRED for these patients

Cardiac: Angina, CHF, MI, CAD, poorly controlled HTN
Resp: Severe asthma, home O2 or ventilation, airway abnormalities
Endocrine: IDDM, active thyroid diseases
Other: Liver disease, ESRD, massive obesity, symptomatic GERD, severe kyphosis, and spinal cord injury


6 Purposes of the Pre-op interview

1) Get medical history
2) Formulate an anesthetic plan
3) Educate the patient
4) Obtain consent
5) Improve efficiency of care and reduce cost
6) Encourage and motivate the patient to achieve a more optimal health status


Tips on how to effectively obtain the patient's medical history during the pre-op interview

1) Organized and systematic
2) Confirm findings from the chart review
3) Use open-ended questions (from general to more specific questions)
4) Use layperson terminology
5) Individualize the interview
6) Optimize the environment (quiet environment, not rushed, +/- family members, lighting, interpreters present, etc)


For females during the pre-op assessment, we want to know about their last

menstrual period


Examples of cardiac questions to ask

Exercise tolerance (How far can you walk or how many flights of stairs can you climb without tiring?)
Any chest pain? When did you last have it? How long does it last? What were you doing when it happened? Are you taking NTG? How frequently?
Ever have an MI? Heart surgery?
So you see a cardiologist? Ever have a stress test? EKG? Cardiac meds?


ASA NPO Guidelines

2 hours for clear liquids
4 hours for breast milk
6 hours for formula or a light meal (nothing greasy)
8 hours for a heavy meal or fatty food, gum, and candy


Does long-term fasting reduce gastric secretions?

Not necessarily


NPO guidelines for those who are an aspiration risk

Guidelines don't exist. Up to provider judgement.


Patients who are at an aspiration risk

Age extremes (70)
Ascites (ESLD)
Collagen vascular diseases
Metabolic disorders (DM, obesity, ESRD, hypothyroidism)
Mechanical obstruction (pyloric stenosis)
Neurologic diseases


During the surgery we want to keep their BP within

20% of their pre-op value


General impression of physical exam

Physical features
Neuro status
Vital Signs


Obesity is defined as

20% over ideal body weight
BMI of 30-39.9


Formula for ideal body weight for men and women

Men: 105lb + 6lb per inch over 5 feet
Women: 100 + 5lb per inch over 5 feet


Normal neck circumference

Men- 17
Women- 16


Order of examination techniques

Inspect, auscultate, percuss, palpate