Cardiac Risk:
Perioperative cardiac complications contribute significantly to perioperative mortality, morbidity, and costs.37 As a result, researchers have focused on identifying the patient at risk for major adverse cardiac events. The best risk prediction model, the Revised Cardiac Risk Index,38 includes six variables:
High-risk surgery (i.e., intraperitoneal, intrathoracic, or suprainguinal vascular procedures)
History of ischemic heart disease (i.e., MI, positive exercise test, presence of angina, use of nitrate therapy, or ECG with Q wave changes).
History of CHF (i.e., pulmonary edema, PND, bilateral rales, S3 gallop rhythm, chest x-ray with vascular redistribution)
History of cerebrovascular disease (i.e., transient ischemic attack or cerebrovascular accident)
Preoperative treatment with insulin
Preoperative creatinine > 176 µmol∙L-1
Once assessed, the patient is given one point for the presence of each risk factor and assigned a Revised Cardiac Risk Index (RCRI) class that corresponds to a percentage value representing the potential for perioperative cardiac complications.
Current Medications and Allergies:
It is important to obtain a detailed list of the patient’s current and recent medications (including all herbal medications) and to note all allergies to drugs. The nature of any adverse reaction should be documented, including the circumstances under which it occurred (e.g., rash, hives, anaphylaxis). Many “allergies” are simply drug side effects, such as nausea and vomiting or pruritus. True allergies to “anesthetic medications” are unusual. Document a careful history of the reaction, and if available, review past medical and anesthetic records.
Particular attention should be paid to cardiovascular and respiratory medications, narcotic analgesics, steroids, and anticoagulants. As a general rule, all medication should be taken with sips of water up to and including the day of surgery. Exceptions to this may include anticoagulants (coumadin, ASA, antiXa inhibitors, and many herbal medications), oral hypoglycemics, insulin (adjustment of the dose is needed on the day of surgery), angiotensin-converting enzyme (ACE) inhibitors, and older generation antidepressants (monoamine oxidase inhibitors, [MAOIs]). Review your local institutional preoperative medication policy.
Physical Examination:
The physical exam should focus on evaluation of the airway as well as the cardiovascular and respiratory systems. Specific attention should be directed to other systems based on comorbidities identified in the preoperative evaluation.
General Inspection:
A general assessment of the patient’s physical and mental status should be performed, and note should be taken of the patient’s vital signs (heart rate, respiratory rate, blood pressure, and oxygen saturation) and biometric measurements (height and weight for calculation of BMI). It is important to check whether the patient is alert, calm, and cooperative, or unusually anxious about the scheduled procedure. Also, does the patient appear young and fit, or elderly, incoherent, emaciated, and bed-ridden? Such obvious differences will dictate the extent and intensity of the examination and the time required to address the patient’s concerns and provide reassurance. The patient’s mental status may also determine the type and amount of premedication required (if any) and may influence the type of anesthetic technique used (general vs regional).
Airway Examination:
Examination of the upper airway should be performed on all patients regardless of their planned anesthetic, as this assessment is used as an indicator of potential difficulty with bag-mask ventilation as well as laryngoscopy and tracheal intubation. Identification of abnormalities in the airway exam will assist in the formulation of a rational plan for airway management. Difficulty in securing the airway is associated with significant patient harm that may be avoided with careful assessment and planning. A detailed discussion on the preoperative airway examination can be found in Chapter 6: Intubation and Anatomy of the Airway.
Cardiovascular Examination:
Assess the patient’s heart rate, rhythm, and blood pressure. Auscultate and identify the first and second heart sounds, and listen for the presence of heart murmurs or a third or fourth heart sound. Identify the location of the apical pulse, and note whether it is abnormally displaced. If indicated (i.e., history of CHF), assess the level of the jugular venous pressure (JVP) and look for the presence of peripheral edema.
Respiratory Examination:
Assess the respiratory rate and work of breathing (i.e., easy and relaxed vs using accessory muscles), and look for the presence or absence of cyanosis or clubbing. Changes in the shape of the thoracic cage may be observed in patients with chronic respiratory disease. The COPD patient with obstructive disease (often referred to as a “blue-bloater”) may have a “barrel”shaped chest that is quite different from a patient with emphysema (commonly referred to as a “pink-puffer”) or the restrictive lung defect associated with kyphoscoliosis. Auscultate the patient’s chest during quiet and forced respiration, listening for bilateral air entry and noting the presence of crackles or wheezes.
Neurological Examination:
A basic neurological assessment should be performed and documented in patients with a history of preexisting motor or sensory weakness as well as in patients about to have a regional nerve block. On general inspection, assess for symmetry, look for the presence of muscular tone, and note any abnormal movements or posturing. Assess sensation in the upper and lower extremities in response to light touch and pain (or temperature). Record any gross motor deficits present prior to the proposed procedure. If neuraxial anesthesia is planned, assess the patient’s back, specifically noting the alignment (examining for scoliosis, kyphosis, or lordosis) and the ability to palpate external landmarks, such as the spinous processes and the anterior superior iliac crests.
Anticipate the need for special invasive monitors, and assess the anatomy for arterial line insertion, central vein cannulation, intravenous access, and major regional anesthetic techniques.
Preoperative Preparation:
The goal of the preoperative evaluation is to gather relevant patient information to formulate an appropriate anesthetic plan. When time permits, this can be a golden opportunity to arrange additional testing and consultations to optimize the patient prior to surgery (e.g., cardiology, respirology, hematology consultations).
The preoperative assessment provides patients with an opportunity to have their questions answered. This may alleviate anxiety and apprehension about the proposed surgery. On occasion, the patient’s anxiety may warrant a preoperative sedation medication. Patients should be instructed to continue or hold existing medications as discussed previously in this Chapter. Preoperative administration of medications for gastroesophageal reflux disease (GERD) or the administration of foundational