The aims of the Preoperative Assessment are risk stratification and identification of medical conditions and their severity (Table 2.1). An additional goal is to ensure that medical management is optimized preoperatively. A review of medications, allergies, NPO (nothing by mouth) status (guidelines are summarized in Table 2.2), and previous experiences with anesthesia should be obtained. Laboratory and physiologic tests and screens can be ordered and reviewed prior to surgery. The American Society of Anesthesiologists (ASA) physical status classification (Table 2.3) stratifies patient risk associated with general anesthesia based on physical status and existing diagnoses (it is not differentiated by type of operation or patient age).
Table 2.1 Preoperative assessment
System
Assessment
Cardiac
Does the patient have hypertension, congestive heart failure, or coronary artery disease?
What medications are currently prescribed?
Does the cardiac status prohibit the patient from achieving 5 METS (up flight of stairs) without shortness of breath?
Review of recent (past-month) ECG for patients older than 45 or those with symptoms
Review of cardiac notes and tests
Respiratory
Does the patient have asthma, COPD, OSA, or reactive airway disease?
Is the patient on medications, home oxygen, or a CPAP device?
Is the patient a smoker?
Does the patient have shortness of breath related to pulmonary conditions?
Review of PFTs, sleep studies, and pulmonary notes
Metabolic
Does the patient have diabetes mellitus or thyroid disease?
Are these conditions optimized?
What medications is the patient currently taking?
NPO status
Has the patient followed the ASA NPO guidelines? (see also Table 1.3)
Alcohol/substance abuse/chronic pain
Does the patient have substance abuse issues that will interact with the pharmacology of an anesthetic?
Will postoperative pain management be complicated by existing opioid dependence?
Has alcohol or drug abuse contributed to organ dysfunction?
Abbreviations: ASA, American Society of Anesthesiologists; CPAP, continuous positive airway pressure; COPD, chronic obstructive pulmonary disease; ECG, electrocardiogram; METS, metabolic equivalents (of oxygen consumption); NPO, nothing by mouth; OSA, obstructive sleep apnea; PFT, pulmonary function test.
Table 2.2 American Society of Anesthesiologists NPO guidelines
Ingested material (unlimited quantity)
Fasting period before anesthesia/procedure begins (minimum time)
Water and clear liquids
2 hours
Infant formula/Nonhuman milk
6 hours
All other liquids and/or a light meal1
6 hours
Breast milk
4 hours
Postpyloric feedings (J-tube)
Do not stop
Gastric (G-tube) feedings
6 hours
Full meal2
8 hours
1. Similar to toast and a clear liquid.
2. Includes meats, fried and/or fatty foods.
Abbreviations: NPO, nothing by mouth.
Table 2.3 American Society of Anesthesiologists (ASA) Physical Status Classification System
ASA Class
Definition
1
Patient has no organic, physiologic, biochemical, or psychiatric disturbance. The pathologic process for which the procedure is to be performed is localized and does not entail systemic disturbance.
2
Patient has mild to moderate systemic disturbance caused either by the condition to be treated surgically or by other pathophysiologic processes.
3
Patient has severe systemic disturbance or disease; variable degree of disability.
4
Patient has severe systemic disorders that may be life-threatening, not always correctable by operation.
5
Seriously ill patient has little chance of survival but has submitted to the operation in desperation.
6
Patient has met brain death criteria and is undergoing organ procurement.
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