General Preoperative Assessment: Difference between revisions

Revision as of 19:51, 24 February 2025

Introduction

The preoperative assessment is the first step in providing effective anesthesia for a patient. It is a process by which the anesthesia provider intentionally evaluates their patient and creates a plan to safely conduct anesthetic care. As many surgeries are becoming outpatient cases, the preoperative assessment is often done on the day of surgery, however, depending on the patient and their comorbidities, the nature of the surgery, and the institution providing care, this assessment can also be done further in advance in a preoperative clinic setting. The major goals of the preoperative assessment are to build rapport with the patient and their support person(s), ensure the patient is medically fit for surgery, perform a physical exam including airway exam, educate on the risks and benefits of the anesthetic plan, determine the need for any special monitors, lab work or medications, and obtain informed consent.

Chart Review

History and Physical

Obtaining a focused yet thorough patient history is a hallmark of the preoperative assessment. History often includes:

Medical history and comorbidities
Indications for the surgery
NPO status
History of previous anesthetics and any known complications (i.e. difficult airway, PONV, intraoperative complications)

Pre-operative Labs

Pre-operative Imaging

ASA Physical Status Classification

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Relevant Article Depot:

Preoperative anesthesia evaluation

Statement on ASA Physical Status Classification System

Paediatric emergencies

Ferrari LR, Leahy I, Staffa SJ, Johnson C, Crofton C, Methot C, Berry JG. One Size Does Not Fit All: A Perspective on the American Society of Anesthesiologists Physical Status Classification for Pediatric Patients. Anesth Analg. 2020 Jun;130(6):1685-1692. PMID: 31219919

Ferrari L, Leahy I, Staffa SJ, Berry JG. The Pediatric-Specific American Society of Anesthesiologists Physical Status Score: A Multicenter Study. Anesth Analg. 2021 Mar 1;132(3):807-817. PMID: 32665468

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+==== Introduction ====
+The preoperative assessment is the first step in providing effective anesthesia for a patient. It is a process by which the anesthesia provider intentionally evaluates their patient and creates a plan to safely conduct anesthetic care. As many surgeries are becoming outpatient cases, the preoperative assessment is often done on the day of surgery, however, depending on the patient and their comorbidities, the nature of the surgery, and the institution providing care, this assessment can also be done further in advance in a preoperative clinic setting. The major goals of the preoperative assessment are to build rapport with the patient and their support person(s), ensure the patient is medically fit for surgery, perform a physical exam including airway exam, educate on the risks and benefits of the anesthetic plan, determine the need for any special monitors, lab work or medications, and obtain informed consent.
+==== Chart Review ====
+==== History and Physical ====
+Obtaining a focused yet thorough patient history is a hallmark of the preoperative assessment. History often includes:
+# Medical history and comorbidities
+# Indications for the surgery
+# NPO status
+# History of previous anesthetics and any known complications (i.e. difficult airway, PONV, intraoperative complications)
+==== Pre-operative Labs ====
+==== Pre-operative Imaging ====
+==== ASA Physical Status Classification ====
 {{Stub Notice}}