Preoperative Assessment). On occasion, time limitations do not permit a complete assessment and optimization of a patient’s condition prior to urgent or emergent surgery. Fig. 2.3 is an overview of the typical flow of a patient to and from the operating room.
Anesthesiology is a fascinating specialty where principles of applied pharmacology, physiology, and anatomy are used to provide care for patients of all ages. It has experienced exponential growth from the humble beginnings of Dr. W.G. Morton’s experience with inhalational anesthetics to our current practice. Like a painter’s brush, no two anesthesiologists have the same practice, and there are subtle nuances that continue to allow for the art as well as the science of medicine. We hope this primer serves as a useful guide during your introduction to our specialty.
References:
1 Marcucci, L. (2010). Inside Surgery. Origin of the Word “Anesthesia”.
1 Astyrakaki E, Papioannou A, Askitopoulou H. (2010). References to anesthesia, pain, and analgesia in the Hippocratic Collection. Anesth Analg 2010; 110(1):188-94.
2 Sullivan J. Surgery before anesthesia. Excerpt from the ASA Newsletter 1966;60(9):8-10.
3 Shepard DAE, Turner KE. (2004). Preserving the Heritage of Canadian Anesthesiology: A panorama of People, Ideas, Techniques and Events.
Chapter 3
Preoperative Evaluation
Raylene Sauvé MD, Gregory Bryson MD
Learning Objectives
1 To develop an understanding of the anesthetic considerations for patients undergoing surgical procedures.
2 To perform a preoperative assessment and formulate an anesthetic plan.
Key Points
1 All preoperative visits should include the following steps: problem identification, perioperative risk assessment, preoperative preparation and proposed plan and technique.
2 It is of paramount importance that anesthesiologists perform a final preanesthetic assessment in the immediate preoperative period to formulate their own “patient-specific” assessment and plan.
3 A patient’s functional capacity is a powerful predictor of postoperative complications.
4 Laboratory and other diagnostic tests should be ordered only when indicated by the patient’s medical co-morbidities or drug therapy or the nature of the proposed surgical procedure.
What is a preoperative assessment, and what is its value to the anesthesiologist?
A preoperative evaluation offers the anesthesiologist an opportunity to define the patient’s medical problems and plan an appropriate anesthetic technique. Additional pre-operative investigations, consultations, and interventions are used to ensure that the patient is in the best possible condition prior to surgery (i.e., preoperative optimization). Following the optimization process, the anesthesiologist can educate and reassure the patient about the procedure, potentially decreasing the patient’s anxiety prior to surgery.
This chapter is intended for care providers who may have little or no exposure to the specialty of anesthesia. It provides the framework to evaluate a patient’s condition, formulate an appropriate anesthetic plan, and communicate this information to colleagues. The preoperative evaluation does not replace the role of the primary care provider and is not meant to address health care issues that are not relevant to the delivery of safe and quality care in the perioperative period.
All preoperative visits should include the following essential steps:
Problem identification
Perioperative risk assessment
Preoperative preparation
Proposed plan for anesthetic techniqu
History of Presenting Illness:
Anesthesiologists must be able to anticipate, avoid, and manage perioperative complications. These complications are specific to the proposed surgery and the patient’s coexisting medical problems. This chapter describes how to use an evaluation of the patient’s history, physical examination, and laboratory investigations to identify and avoid potential problems, assess the severity of the patient’s condition, and optimize the patient’s condition prior to surgery. The first step is to ask the patient to explain the reason for the surgery. Ascertain information about the nature of the problem; determine its severity and any therapeutic interventions that have been used. Careful consideration of the surgical procedure will determine the likelihood of significant blood loss, cardiorespiratory compromise, or unusual positioning requirements (i.e., prone, lateral, lithotomy, etc.). This information can also be useful in planning for venous access, specific monitoring, and choice of anesthetic technique.
Anesthetic History:
The patient undergoing anesthesia and surgery should be carefully questioned about any reaction to previous anesthetics, and information that the patient considers relevant should be documented. A review of the patient’s previous anesthetic records may provide additional information concerning any prior perioperative complications and may offer solutions to avoid similar problems in the future.
The patient should be asked about a family history of adverse anesthetic problems. Malignant hyperthermia and plasma cholinesterase deficiency are two such hereditary disorders that manifest under anesthesia (for further information, see Chapter 25: Unusual Anesthetic Complications).
Problem Identification:
Anesthetic drugs and techniques can have a profound effect on human physiology. The anesthesiologist uses the preoperative evaluation to identify medical conditions that may be adversely affected by the administration of anesthetic medications. Special attention is paid to symptoms and diseases related to the cardiovascular, respiratory, and neuromuscular systems as they will be directly influenced by the anesthetic medications. A systems-based review can be used to illicit additional relevant information. Ask the patient general screening questions directed at all major body systems, and then narrow the focus if the patient gives positive responses to any of the questions. This information can then be used to develop an appropriate “patient-specific” anesthetic plan.
When available, a recent preoperative evaluation may be used to guide the assessment. Even when the patient has been seen in a pre-assessment clinic, it is of paramount importance that anesthesiologists perform a final preanesthetic assessment to formulate their own assessment and plan. The final preoperative evaluation should include a review of the patient’s history, physical examination, and most recent investigations.
Optimization prior
