Anesthesia Rotation Primer  (2 of 8)

Preoperative Evaluation

Before any patient undergoes surgery, they have to be assessed.  This preoperative evaluation serves several goals.  During this meeting, certain key points in the patient’s medical history and physical exam are identified to help determine whether further tests or consults are needed, and to uncover risk factors that can guide our choice of anesthesia plan.  This is also the best time to establish patient rapport, educate the patient about the perioperative process, and obtain informed consent.

To achieve those goals, the preoperative evaluation is highly focused on three areas— Miller’s Rule of Three’s: the acute history, chronic history, and physical exam.

Acute History

1.             Exercise Tolerance.  How well can the patient’s heart handle the stress of surgery and anesthesia?  (In practice, a patient who can climb 2 flights of stairs without stopping has no increased perioperative cardiac risk.)

2.             History of Present Illness.  Has the patient been acutely ill?  Has the patient been in a hospital, ER, or had surgery in the last 2 years?  If so, for how long and why?  (Details about previous admissions can help you understand disease severity, identify other risk factors, and help avoid potential problems patients may have had before, such as difficult airway management, adverse reactions, or post-op nausea.)

3.             Last Primary Care Physician Visit.   Has the patient been medically optimized to undergo the stress of surgery?  (Poor medical follow-up may point to a need for further consults or evaluation.)

Chronic History

1.             Medications and Allergies.  Why is the patient using these medications?  (This helps identify more underlying illnesses and risk factors.  Also, several medications can influence choice of anesthetics.)  Which medications were taken today?  (Some, like antihypertensives, are best continued until the day of surgery, while others, like oral hypoglycemics, are avoided on the morning of surgery.)

2.             Social History.  Active smokers are at higher risk for airway hyperreactivity and pulmonary complications perioperatively.  Chronic alcoholism leads to higher dose requirements for anesthetics, while narcotic abuse causes tolerance to opioids both during and after surgery.

3.             Family History.  Has anyone in the family had any unusual or adverse reactions under anesthesia?  (Malignant hyperthermia, although rare, is a hereditary disease that can be rapidly fatal if unsuspected.)

Physical Examination

1.             Airway.  Specific findings may indicate a difficult airway, including poor mouth opening, poor cervical mobility, a short thyromental distance or receding chin, a large tongue or prominent incisors, and a short, muscular neck.  The famous Mallampati classification helps predict difficult visualization during laryngoscopy.

2.             Cardiovascular.  Look for murmurs, arrhythmias, gallop rhythms, or a pericardial rub.

3.             Pulmonary.  Auscultate for wheezing, rales, or rhonchi.  Check for tracheal deviation.

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