OnExam

Identifying Information

Gather the patient's general identifying data.

Reason for Surgery

  • Have the patient explain the reason for the surgery.
  • Determine the severity and any therapeutic interventions that have been used.

Anesthetic History

  • Previous surgeries
  • Previous anesthetics used (e.g., General Anesthesia, Neuraxial Anesthesia)
  • Previous anesthetic complications or adverse reactions
    • Malignant Hyperthermia
    • Plasma cholinesterase deficiency
    • Post-operative nausea or vomiting

NPO Status

  • When did the patient last have solid food?
  • When did the patient last have liquids?
    • Allowance may differ between hospitals. Typically, 8 hours without solid food and 4 hours without clear fluids pre-operatively is the standard.

Review of Systems

Although similar to the Review of Systems performed in a regular history, the pre-operative Review of Systems has unique elements and will include the patient’s Past Medical History.

Functional Capacity

Determine the functional capacity of your patient in metabolic equivalents.

  • 1 MET ADLs (eat, dress, use toilet)
  • 2-3 MET walk indoors, walk one to two blocks on level ground
  • 4 MET climb 1 flight of stairs without stopping or feeling SOB
  • 5-9 MET recreational activities, run a short distance, heavy housework (scrubbing floors, lifting furniture)
  • 10 MET strenuous sports (swimming, tennis, football, basketball, skiing)

Cardiovascular System HPI

Angina (OPQRST)

  • New onset (<2mo). Stable vs unstable.
  • Previous MI - If so, how was this managed (PCI, CABG)
  • Functional class – Canadian Cardiovascular Society (CCS)

Symptoms of Heart Failure

  • Fatigue, syncope
  • Dyspnea, orthopnea, paroxysmal nocturnal dyspnea (PND)
  • Peripheral edema
  • Functional Class - New York Heart Association (NYHA)

Symptoms of Peripheral Vascular Disease

  • Claudication (acute, localized pain to muscle groups, reproducible dependent on exertion)
  • 6 P's (polar, pain, pallor, paraesthesia, paralysis, pulselessness)

Palpitations, syncope

Past Cardiac History

  • High Risk Conditions
  • Revised Goldman Cardiac Risk Index
    • History of MI
    • History of CHF
    • History of CVA/TIA
    • Diabetes mellitus requiring insulin
  • Thrombotic Risk Factors
    • Recent MI (<3 months)
    • Previous PE/DVT
    • Arrhythmia (atrial fibrillation)
    • Valvular Heart Disease
    • Vasculitis
    • Post-operative / Trauma
    • Estrogen-related (pregnancy; contraceptive; smoking)
    • Malignancy or inherited hypercoagulable state
  • Recent Investigations / Procedures
    • ECG, Echo, Angiography, Surgery
  • Medications
    • Anti-platelets / Anti-thrombotics
    • Anti-hypertensives (anti-HTN)
    • Anti-arrhythmics
    • Diuretics
    • Lipid-modifying

Respiratory History

Smoking (>20pack years)

  • Preoperative smoking associated with an increased risk of postoperative complications, including pulmonary (RR 1.73, 95% CI 1.35-2.23)9
  • 4 weeks of smoking cessation lowers total postoperative complications (RR 0.59, 95% CI 0.41-0.85) with an increase in the magnitude of effect of 19 percent for each week of cessation10.

COPD

  • Ask about Chronic cough, Home oxygen, Hospitalizations, Recent steroid use
  • Relative Risk ranges from 2.7 to 6.08
  • Patients with severe COPD are 6x more likely to have major post-operative pulmonary complications after abdominal/thoracic surgery, than those without
  • There appears to be no prohibitive level of pulmonary function below which surgery should be absolutely contraindicated

Asthma

  • Triggers
  • Frequency and severity of asthma attacks
  • Frequency and last administration of rescue inhaler (i.e., salbutamol)
  • Conflicting evidence for pre-operative management for patients with asthma

Obesity

  • Physiologic changes accompanying obesity include reduced lung volumes, ventilation/perfusion mismatch, relative hypoxemia
  • Obesity has not consistently shown to be a significant, independent risk factor for postoperative pulmonary complications
  • It should not affect patient selection for otherwise high-risk procedures6

Sleep Apnea

  • If obstructive sleep apnea (OSA) has been diagnosed with a sleep study, ask if they are using a CPAP machine
  • Increased risk of early post-operative hypoxemia and unplanned reintubation11
  • STOP-BANG Screening questionnaire12
    • Do you Snore loudly? (closed doors, affects partner)
    • Do you feel Tired or sleepy during the daytime? (falling asleep at work, while driving)
    • Has anyone Observed you stop breathing, choking/gasping during sleep?
    • Have you been treated for high blood Pressure?
    • BMI >35kg/m2
    • Age >50yrs
    • Neck circumference >43cm(males) >41cm (females)? (measured at cricoid cartilage)
    • Gender = male?
    • Intermediate-High Risk: Score ≥3 predicts preoperative OSA of any severity (Sensitivity 84; Specificity 40%)
    • High Risk:≥5 considered high risk (probability 30.1%)

Pulmonary HTN

  • Mild to moderate pulmonary HTN increases post-op respiratory failure, cardiac dysrhythmias, heart failure, renal insufficiency, and sepsis
  • Features associated with increased risk among these patients include: pulmonary embolus, NYHA functional class ≥2, intermediate or high-risk surgery, and duration of anesthesia >3 hours13,14,15

General Health Status (ASA >2)

  • ASA classification correlates well with pulmonary risk
  • ASA class >2 (4.87x increase in risk (95% CI 3.34-7/10))6
    • AMERICAN SOCIETY OF ANESTHESIOLOGISTS (ASA) CLASSIFICATION3:

      • 1 - healthy patient with no disease outside of surgical process (<0.03% mortality)
      • 2 - mild to moderate systemic disease caused by the surgical condition or other diseases, medically well controlled (0.2% mortality)
      • 3 - severe disease process, which limits activity but is not incapacitating (1.2% mortality)
      • 4 - severe incapacitating disease process that is a constant threat to life (8% mortality)
      • 5 - moribund patient, not expected to survive 24 h with or without an operation (34% mortality)
      • E - suffix for emergency surgery for any class

    Central Nervous System

  • Seizures
  • Stroke or TIA
  • Raised ICP
  • Musculoskeletal

    • Diseases of neuromuscular junction (e.g., myasthenia gravis)
    • Muscular dystrophy
    • Rheumatoid arthritis
      • Risk for instability of cervical spine
    • Trisomy 21
      • Risk for instability of cervical spine
    • Cervical spine trauma/injuries/infection

    Endocrine

    • Diabetes Mellitus
      • End-organ dysfunction secondary to DM
      • Blood-glucose control
      • Treatment: lifestyle modifications, oral hypoglycemics, and/or insulin
    • Thyroid disease
      • Hypothyroidism
      • Hyperthyroidism
    • Corticosteroid use within last year
      • Dose of prednisone greater than 20mg per day for more than 5 days in the past 12 months increases the risk of postoperative adrenal insufficiency

    Gastrointestinal and Hepatic Systems

    • Gastroesophageal reflux disease (GERD)
      • Frequency
      • Triggers
      • Medications to control GERD
    • Hepatic disease

    Renal System

    • Renal Insufficiency
      • Whether or not on dialysis

    Hematological System

  • Anemia
  • Bleeding dyscrasias
  • Coagulopathies
  • Psychiatric

  • Dementia or cognitive dysfunction
  • History of delirium
  • Dental

    • Recent dental work
      • Caps or crowns
    • Dentures
    • Loose teeth

    Reproductive History

    • For women:
      • Last menstrual period?
      • Is there a chance of pregnancy?

    Family History

    • Malignant Hyperthermia
    • Pseudocholinesterase deficiency
    • Adverse drug reactions

    Social History

    • Smoking (should already have asked with respiratory system)
    • Illicit drug use
    • Alcohol
      • Quantify amount

    Medications

    • Ask about all the medications (including herbal medications) that the patient is currently taking
    • If on the day of surgery, ask which medications the patient took that day. Specific medications to ask about include:
      • Opioids
      • Hypertension medications
      • Beta-blockers
      • Inhalers, particularly salbutamol use that day
      • Steroids
      • Anticoagulants

    Substance Use History (SubHx)

    Specifically ask about:

    Allergies

    Note allergies and ensure they concord with those listed in the EMR

    References

    • Patrick Sullivan MD. “Ottawa Anesthesia Primer.” Echo Book Publishing, 2013.
    • Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology 2008 May;108(5):812-21.