- Preoperative Exam History
Reason for Surgery
- Have the patient explain the reason for the surgery.
- Determine the severity and any therapeutic interventions that have been used.
- 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
- 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.
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
- 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)
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
- Post-operative / Trauma
- Estrogen-related (pregnancy; contraceptive; smoking)
- Malignancy or inherited hypercoagulable state
- Recent Investigations / Procedures
- ECG, Echo, Angiography, Surgery
- Anti-platelets / Anti-thrombotics
- Anti-hypertensives (anti-HTN)
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.
- 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
- 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
- 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
- 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%)
- 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
Central Nervous System
Stroke or TIA
- 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
- Diabetes Mellitus
- End-organ dysfunction secondary to DM
- Blood-glucose control
- Treatment: lifestyle modifications, oral hypoglycemics, and/or insulin
- Thyroid disease
- 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)
- Medications to control GERD
- Hepatic disease
- Renal Insufficiency
- Whether or not on dialysis
Dementia or cognitive dysfunction
History of delirium
- Recent dental work
- Loose teeth
- For women:
- Last menstrual period?
- Is there a chance of pregnancy?
- Malignant Hyperthermia
- Pseudocholinesterase deficiency
- Adverse drug reactions
- Smoking (should already have asked with respiratory system)
- Illicit drug use
- 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:
- Hypertension medications
- Inhalers, particularly salbutamol use that day
Substance Use History (SubHx)
Specifically ask about:
Note allergies and ensure they concord with those listed in the EMR
- 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.