Preoperative

Evaluation
Anesthesia Preoperative
Evaluation
1. The overall goal of the preoperative
evaluation is to reduce perioperative
morbidity and mortality and alleviate patient
anxiety.
2. Anesthesia preoperative history and
physical
A. Note the date and time of the interview,
the planned procedure, and a description of
any extraordinary circumstances regarding
the anesthesia.
B. Current medications and allergies:
history of steroids, chemotherapy and herb
and dietary supplements (see tables).
C. Cigarette, alcohol, and illicit drug history,
including most recent use.
D. Anesthetic history, including specific
details of any problems.
E. Prior surgical procedures and
hospitalizations.
F. Family history, especially anesthetic
problems. Birth and development history
(pediatric cases).
G. Obstetrical history: last menstrual
period (females).
H. Medical history; evaluation, current
treatment, and degree of control.
I. Review of systems, including general,
cardiac, pulmonary, neurologic, liver, renal,
gastrointestinal, endocrine, hematologic,
psychiatric.
J. History of airway problems (difficult
intubation or airway disease, symptoms of
temporomandibular joint disease, loose
teeth, etc).
K. Last oral intake.
L. Physical exam, including airway
evaluation (see below), current vital signs,
height and body weight, baseline mental
status, evaluation of heart and lungs,
vascular access.
M.Overall impression of the complexity of
the patients medical condition, with
assignment of ASA Physical Status Class
(see below).

N. Anesthetic plan (general anesthesia,

regional, spinal, MAC). The anesthetic plan
is based on the patient's medical status, the
planned operation, and the patients wishes.
O. Documentation that risks and benefits
were explained to the patient.
3. Preoperative laboratory evaluation
A. Hemoglobin: menstruating females,
children less than 6 months or with
suspected sickle cell disease, history of
anemia, blood dyscrasia or malignancy,
congenital heart disease, chronic disease
states, age greater than 50 years (65 years
for males), patients likely to experience
large
blood loss.
B. WBC count: suspected infection or
immunosuppression.
C. Platelet count: history of abnormal
bleeding or bruising, liver disease, blood
dyscrasias, chemotherapy, hypersplenism.
D. Coagulation studies: history of
abnormal bleeding, anticoagulant drug
therapy, liver disease, malabsorption, poor
nutrition, vascular procedure.
E. Electrolytes, blood glucose,
BUN/creatinine: renal disease, adrenal or
thyroid disorders, diabetes mellitus, diuretic
therapy, chemotherapy.
F. Liver function tests: patients with liver
disease, history of or exposure to hepatitis,
history of alcohol or drug abuse, drug
therapy with agents that may affect liver
function.
G. Pregnancy test: patients for whom
pregnancy might complicate the surgery,
patients of uncertain status by history and/or
examination.
H. Electrocardiogram: age 50 or older,
hypertension, current or past significant
cardiac disease or circulatory disease,
diabetes mellitus in a person age 40 or
older. An EKG showing normal results that
was performed within 6 months of surgery
can be used if there has been no
intervening clinical event.
I. Chest x-ray: asthma or chronic
obstructive pulmonary disease with change
of symptoms or acute episode within the
past 6 months,
cardiothoracic procedures.

J. Urinalysis: genito-urologic procedures;

surgeon may request to rule out infection
before certain surgical procedures.
K. Cervical spine flexion/extension xrays: patients with rheumatoid arthritis or
Downs syndrome. Routine screening in
asymptomatic patients is generally not
required.
L. Preoperative pulmonary function tests
(PFTs)
1. There is no evidence to suggest that
pulmonary function tests are useful for
purposes of risk assessment or modification
in patients with
cigarette smoking or adequately treated
brochospastic disease.
2. Candidates for preoperative PFTs
A. Patients considered for pneumonectomy.
B. Patients with moderate to severe
pulmonary disease scheduled for major
abdominal or thoracic surgery.
C. Patients with dyspnea at rest.
D. Patients with chest wall and spinal
deformities.
E. Morbidity obese patients.
F. Patients with airway obstructive lesions.
4. Pediatric preoperative evaluation: see
section on pediatric anesthesia.

Airway Evaluation
1. Preoperative evaluation: assessed by
historical interview (ie, history of difficult
intubation, sleep apnea) and physical
examination and occasionally
with radiographs, PFTs, and direct fiberoptic examination. The physical exam is the
most important method of detecting and
anticipating airway
difficulties.
2. Physical exam
A. Mouth
1. Opening: note symmetry and extent of
opening (3 finger breadths optimal).
2. Dentition: ascertain the presence of
loose, cracked, or missing teeth; dental
prostheses; and co-existing dental
abnormalities.
3. Macroglossia: will increase difficultly of
intubation.
B. Neck/Chin

1. Anterior mandibular space

(thyromental
distance): the distance between the hyoid
bone and the inside of the mentum (mental
prominence) or between the notch of the
thyroid cartilage to the mentum. An
inadequate mandibular space is associated
with a hyomental distance of <3 cm or a
thyromental distance of <6 cm.
2. Cervical spine mobility (atlantooccipital
joint extension): 35 degrees of extension
is normal; limited neck extension (<30
degrees associated with increased difficulty
of intubation.
3. Evaluate for presence of a healed or
patent tracheostomy stoma; prior surgeries
or pathology of the head and neck
(laryngeal cancer); presence of a hoarse
voice or stridor.
3. Airway classification
A. Mallampati classification (relates
tongue size vs pharyngeal size).
1. Class 1: able to visualize the soft palate,
fauces, uvula, anterior and posterior
tonsillar pillars.
2. Class 2: able to visualize the soft palate,
fauces, and uvula. The anterior and
posterior tonsillar pillars are hidden by the
tongue.
3. Class 3: only the soft palate and base of
uvula are visible.
4. Class 4: only the soft palate can be seen
(no uvula seen).
B. Laryngoscopic view grades
1. Grade 1: full view of the entire glottic
opening.
2. Grade 2: posterior portion of the glottic
opening is visible.
3. Grade 3: only the epiglottis is visible.
4. Grade 4: only soft palate is visible.
4. Predictors of difficult intubation
A. Anatomic variations: micrognathia,
prognathism, large tongue, arched palate,
short neck, prominent upper incisors,
buckteeth, decreased jaw movement,
receding mandible or anterior larynx, short
stout neck.
B. Medical conditions associated with
difficult
intubations

1. Arthritis: patients with arthritis may have

a decreased range of neck mobility.
Rheumatoid arthritis patients have an
increased risk of atlantoaxial subluxation.
2. Tumors: may obstruct the airway or
cause extrinsic compression and tracheal
deviation.
3. Infections: of any oral structure may
obstruct the airway.
4. Trauma: patients are at increased risk for
cervical spine injuries, basilar skull
fractures, intracranial injuries, and facial
bone fractures.
5. Downs Syndrome: patients may have
macroglossia, a narrowed cricoid cartilage,
and a greater frequency of postoperative
airway obstruction/croup; risk of subluxation
of the atlanto-occipital joint.
6. Scleroderma: may result in decreased
range of motion of the temporomandibular
joint and narrowing of the oral aperture.
7. Obesity: massive amount of soft tissue
about the head and upper trunk can impair
mandibular and cervical mobility, increased
incidence of
sleep apnea.

ASA Physical Status

Classification
1. The ASA (American Society of
Anesthesiologists) physical status
classification has been shown to generally
correlate with the perioperative mortality
rate (mortality rates given below).
2. ASA 1: a normal healthy patient (0.060.08%).
3. ASA 2: a patient with a mild systemic
disease (mild diabetes, controlled
hypertension, obesity [0.27- 0.4%]).
4. ASA 3: a patient with a severe systemic
disease that limits activity (angina, COPD,
prior myocardial infarction [1.8-4.3%]).
5. ASA 4: a patient with an incapacitating
disease that is a constant threat to life
(CHF, renal failure [7.8-23%]).
6. ASA 5: a moribund patient not expected
to survive 24 hours (ruptured aneurysm
[9.4-51%]).
7. ASA 6: brain-dead patient whose organs
are being harvested.

8. For emergent operations, add the letter

E after the classification.

Preoperative Fasting Guidelines

1. Recommendations (applies to all ages)
Ingested Material Minimum Fasting
Period (hrs)
Clear liquids 2, Breast milk 4, Infant
formula 6, Non-human milk 6, Light solid
foods 6
2. Recommendations apply to healthy
patients exclusive of parturients undergoing
elective surgery; following these
recommendations does not guarantee
gastric emptying has occurred.
3. Clear liquids include water, sugar-water,
apple juice, non-carbonated soda, pulp-free
juices, clear tea, black coffee.
4. Medications can be taken with up to 150
mL of water in the hour preceding induction
of anesthesia.

Bacterial Endocarditis
Prophylaxis
1. Antibiotic prophylaxis is recommended
for patients with prosthetic cardiac valves,
previous history of endocarditis, most
congenital malformations, rheumatic
valvular disease, hypertrophic
cardiomyopathy, and mitral valve
regurgitation.
2. Prophylactic regimens for dental, oral,
respiratory tract, or esophageal
procedures
A. Standard regimen
1. Adults: amoxicillin 2 g PO 1 hour before
procedure.
2. Children: amoxicillin 50 mg/kg PO 1 hour
before procedure.
B. Unable to take oral medications
1. Adults: ampicillin 2 g IM/IV within 30 min
before procedure.
2. Children: ampicillin 50 mg/kg IM/IV
within 30 min before procedure.
C. Penicillin allergic
1. Adults: clindamycin 600 mg or
cephalexin (or cefadroxil) 2 g or
azithromycin (or clarithromycin) 500 mg 1
hour before procedure.
2. Children: clindamycin 20 mg/kg PO or
cephalexin (or cefadroxil) 50 mg/kg or

azithromycin (or clarithromycin) 15 mg/kg 1

hour before procedure
D. Allergic penicillin and unable to take
oral medications
1. Adults: clindamycin 600 mg IV or
cefazolin 1 g within 30 min before
procedure.
2. Children: clindamycin 20 mg/kg IV or
cefazolin 25 mg/kg IM/IV within 30 min
before procedure.
3. Prophylactic regimens for
genitourinary/gastrointestinal (excluding
esophageal) procedures
A. High-risk patients
1. Adults: ampicillin 2 g IM/IV plus
gentamicin 1.5 mg/kg (not to exceed 120
mg) within 30 min before procedure; 6 hours
later ampicillin 1 g
IM/IV or amoxicillin 1 g PO.
2. Children: ampicillin 50 mg/kg IM/IV (not
to exceed 2 g) plus gentamicin 1.5 mg/kg
within 30 min before procedure; 6 hours
later, ampicillin 25 mg/kg IM/IV or
amoxicillin 25 mg/kg PO.
B. High-risk patients allergic to
ampicillin/amoxicillin
1. Adults: vancomycin 1 g IV over 1-2 h
plus gentamicin 1.5 mg/kg IM/IV (not to
exceed 120 mg); complete within 30 min
before procedure.
2. Children: vancomycin 20 mg/kg IV over
1-2 h plus gentamicin 1.5 mg/kg IM/IV;
complete within 30 min before procedure.
C. Moderate-risk patients
1. Adults: amoxicillin 2 g PO 1 hour before
procedure, or ampicillin 2 g IM/IV within 30
min before procedure.
2. Children: amoxicillin 50 mg/kg PO 1 hour
before procedure, or ampicillin 50 mg/kg 30
min before procedure.
D. Moderate-risk patients allergic to
ampicillin/amoxicillin
1. Adults: vancomycin 1 g IV over 1-2
hours; complete infusion within 30 min
before starting procedure.
2. Children: vancomycin 20 mg/kg IV over
1-2 hours; complete 30 min before starting
procedure.
4. Miscellaneous notes
A. Total dose for children should not exceed
the adult dose.

B. Cephalosporins should not be used in

individuals with immediate-type
hypersensitivity reaction (urticaria,
angioedema, or anaphylaxis) to penicillin.
C. Patients already taking antibiotics for
another reason should be given an agent
from a different class for endocarditis
prophylaxis.
D. Patients at risk for endocarditis who
undergo open heart surgery should have
prophylaxis directed primarily at
staphylococci.
E. Cardiac transplant recipients should
probably be considered at moderate risk for
endocarditis and receive prophylaxis
accordingly.

Premedications
1. The goals of premedications include:
anxiety relief, sedation, analgesia, amnesia,
antisialagogue effect, increase in gastric
fluid pH, decrease in gastric fluid volume,
attenuation of sympathetic nervous system
reflex responses, decrease in anesthetic
requirements, prevent bronchospasm,
prophylaxis against allergic reactions, and
decrease post-op nausea/vomiting.
2. Sedatives and analgesics should be
reduced or withheld in the elderly,
newborn/peds (<1 year of age), debilitated,
and acutely intoxicated, as well as those
with upper airway obstruction or trauma,
central apnea, neurologic deterioration, or
severe pulmonary
or valvular heart disease.