General Preoperative Assessment
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 (include gestational age, complications at birth/NICU admission)
- Family history of complications with anesthetics (i.e. malignant hyperthermia, pseudocholinesterase deficiency)
- Indications for the surgery
- NPO status
- History of previous anesthetics and any known complications (i.e. difficult airway, PONV, intraoperative complications)
- History of current/recent upper respiratory tract infections
- Any known allergies
- Medications
- Review of systems
Medical History - obvious reasons
Family History - important to ask as many first anesthetic for most
Indication for surgery - positioning
NPO status - insert NPO time table. important for decreasing aspiration risk
Prev anes- guide your current plan
URI - case cancellation, laryngospasm risk
Allergies- how food allergies can suggest propofol or latex allergy
Meds - drug interactions
ROS - insert another table
Pre-operative Labs
Pre-operative Imaging
ASA Physical Status Classification
This is a Stub Notice. This page has not been completed. You can work on this page by signing in and going to the Edit tab. Thanks for helping to make PedsAnesthesia.Net Wiki useful.
Go to the Main Page to see the Topic Outline.
Go to the Generalized Suggested Outline for information on case-specific details for each page.
Go to the Test Page for examples on how to use references in the page.
Relevant Article Depot:
Preoperative anesthesia evaluation