3  PREPARING FOR ANESTHESIA

CHAPTER 17 
PREOPERATIVE EVALUATION
James C. Duke, MD, MBA, and Mark Chandler, MD

1. What are the goals of the preoperative evaluation?

The preoperative evaluation consists of gathering information about the patient and
formulating an anesthetic plan. The overall objective is a smooth anesthetic without
perioperative morbidity and mortality.
2. Discuss the important features of the preoperative evaluation.
The anesthesiologist should review the surgical plan. Medical records review and focused
physical examination are essential. Include allergies, medications, herbal supplements, drugs
of abuse, review of systems, and prior anesthetic problems (e.g., difficult intubation, delayed
emergence, malignant hyperthermia, prolonged neuromuscular blockade, or postoperative
nausea and vomiting). There may be concerning features that warrant specialty
consultation.
3. What is the physical status classification of the American Society of
Anesthesiologist (ASA)?
The ASA classification was created in 1940 for the purposes of statistical studies and
hospital records. It is useful both for outcome comparisons and as a means of
communicating the physical status of a patient. Unfortunately it is imprecise and is a
subject of disagreement. Finally, a higher ASA class only roughly predicts anesthetic risk.
The six classes are:
• Class 1: A normal healthy patient
• Class 2: A patient with mild systemic disease
• Class 3: A patient with severe systemic disease
• Class 4: A patient with severe systemic disease that is a constant threat to life
• Class 5: A moribund patient who is not expected to survive without the operation
• Class 6: A declared brain-dead patient whose organs are being removed for donor
purposes
Add an “E” for any unplanned or emergent procedure.
4. What are the features of informed consent?
The anesthetic must be conveyed, thorough, and in terms the patient understands. Often a
translator is needed for a patient who speaks a foreign language. Include also cultural
sensitivities.
5. Review appropriate pediatric fasting periods.
See Table 17-1. Current guidelines for pediatric patients include:
• Clear liquids up to 2 hours before surgery
• Breast milk up to 4 hours before surgery
• Solid foods, including nonhuman milk and formula, up to 6 hours before surgery
Guidelines may be modified if the child has gastrointestinal or airway concerns.
6. What are the appropriate preoperative laboratory tests?
No evidence supports the use of routine laboratory testing. Rather, there is support for the
use of selected laboratory analysis based on the patient’s circumstances (Table 17-2). Chest
radiographs are rarely indicated. Chemistries should be drawn if electrolyte abnormalities
are suspected. Patients with diabetes should have glucose checks. Hemoglobin and
hematocrit values are reviewed if the patient appears anemic or if blood loss is anticipated.
Coagulation studies are a function of history or bleeding stigmata.

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 114  PREPARING FOR ANESTHESIA

Table 17-1.  General Preoperative Fasting Recommendations

MINIMUM FASTING
INGESTED MATERIAL PERIOD (HOURS)
Clear liquids (e.g., water, fruit juices without pulp, carbonated 2
beverages, clear tea and black coffee; clear liquids should not
include alcohol)
Breast milk 4
Infant formula 6
Nonhuman milk 6
Light meal (a light meal typically consists of toast and clear liquids) 6
Full, heavy, fatty meal 8

Table 17-2.  Appropriate Preoperative Laboratory Tests Based on Patient History

and Physical Examination*
TEST INDICATIONS
Electrocardiogram Cardiac and circulatory disease, respiratory disease, advanced age†
Chest radiograph Chronic lung disease, history of congestive heart disease
Pulmonary function Reactive airway disease, chronic lung disease, restrictive lung disease
tests
Hemoglobin/ Advanced age,† anemia, bleeding disorders, other hematologic
hematocrit disorders
Coagulation studies Bleeding disorders, liver dysfunction, anticoagulants
Serum chemistries Endocrine disorders, medications, renal dysfunction
Pregnancy test Uncertain pregnancy history, history suggestive of current pregnancy
*At least 50% of the task force experts agreed that the listed tests were beneficial when used selectively.
Because of a lack of solid evidence in the literature, these indications are somewhat broad and vague and
limit the clinical use of the guidelines.
†
The definition of advanced age is vague and should be considered in the context of that patient’s overall
health.

7. What is the generally accepted minimum hemoglobin or hematocrit (H/H) for

elective surgery?
It depends on the clinical setting. Surgeries without significant blood loss do not add any
value. However, elderly anemic patients often have a poorer functional status, longer
hospitalizations, and higher 1-year mortality.
8. When are consultations indicated?
Specialty consultations are indicated when history, physical examination and other
diagnostic data require specialty expertise to further risk stratify patients undergoing
anesthesia. Cardiac consultations are probably most frequent, due in large part to the
ambiguous nature of the symptoms of myocardial ischemia.
9. What are the clinical risk factors for a major perioperative cardiac event?
The Revised Cardiac Risk Index (Box 17-1) has six components:
• High-risk surgical procedures
• History of ischemic heart disease

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 Preoperative Evaluation  115

Box 17-1.  Revised Cardiac Risk Index

Each of the following six risk factors is assigned one point.
1. High-risk surgical procedures
Intraperitoneal
Intrathoracic
Suprainguinal vascular
2. History of ischemic heart disease
History of myocardial infarction
History of positive exercise test
Current complaint of chest pain considered secondary to myocardial ischemia
Use of nitrate therapy
Electrocardiogram with pathologic Q waves
3. History of congestive heart failure
Pulmonary edema
Paroxysmal nocturnal dyspnea
Bilateral rales or S3 gallop
Chest radiograph showing pulmonary vascular redistribution
4. History of cerebrovascular disease
History of transient ischemic attack or stroke
5. Preoperative treatment with insulin
6. Preoperative serum creatinine >2 mg/dl
Risk of Major Cardiac Event
Points Class Risk
0 I 0.4%
1 II 0.9%
2 III 6.6%
3 or more IV 11%

Major cardiac events include myocardial infarction, pulmonary edema, ventricular fibrillation, primary cardiac arrest, and complete
heart block.

• History of congestive heart failure

• History of cerebrovascular disease
• Preoperative treatment with insulin
• Elevated preoperative serum creatinine
The patient is assigned one point for each of these risk factors, which are then translated
into percentage risks of perioperative major cardiac events such as myocardial infarction,
pulmonary edema, ventricular fibrillation, primary cardiac arrest, and complete heart block.
10. What are active cardiac conditions?
Active cardiac conditions are serious cardiac conditions that warrant immediate evaluation
and treatment before undergoing surgery. There are four active cardiac conditions:
• Unstable coronary syndromes, which include unstable or severe angina and recent
myocardial infarction
• Decompensated heart failure
• Significant arrhythmias such as symptomatic ventricular arrhythmias, high-grade
atrioventricular block, and symptomatic bradycardia
• Severe valvular disease such as symptomatic mitral stenosis or severe aortic stenosis
11. Are there ways of predicting postoperative pulmonary complications?
Among the most common risk factors for postoperative pulmonary complications (PPCs)
are chronic obstructive pulmonary disease and advanced age. Observed PPC abnormalities
rarely result in postoperative mortality; thus most surgeries may be performed even when
these risk factors are present (Table 17-3).

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 116  PREPARING FOR ANESTHESIA

Table 17-3.  Risk Factors for Postoperative Pulmonary Complications

PREOPERATIVE RISK FACTORS INTRAOPERATIVE RISK FACTORS
COPD Site of surgery
Age General anesthesia
Inhaled tobacco use Pancuronium use
NYHA class II pulmonary hypertension Duration of surgery
OSA Emergency surgery
Nutrition status
COPD, Chronic obstructive pulmonary disease; NYHA, New York Heart Association; OSA, obstructive sleep
apnea.
From the New York Heart Association (NYHA).

Indications for pulmonary function testing are addressed in Chapter 9

KEY PO I N T S : P R E O P E R A T I V E E V A L U A T I O N
1. Preoperative laboratory testing should be selective and individualized.
2. Current ACC/AHA guidelines for cardiac testing prior to noncardiac procedures are the gold
standard for preoperative cardiac risk assessment.
3. The most important preanesthetic evaluation includes a thorough, accurate, and focused history
and physical examination.
4. A patient’s baseline hemoglobin tends to predict the need for transfusion when large blood loss
occurs.
5. The four active cardiac conditions that will likely result in surgical cancellation to assess cardiac
evaluation and treatment are unstable coronary syndrome, decompensated heart failure,
significant cardiac arrhythmias, and severe valvular disease.
6. Before halting a patient’s anticoagulation, one must consider the type and urgency of surgery, the
possibility and consequences of intraoperative hemorrhage, and the reason why the patient is
anticoagulated

12. What benefits and risks are associated with preoperative cigarette cessation?
How long before surgery must a patient quit smoking to realize any health
benefits?
Patients randomized to receive an intervention to help them stop smoking 6 to 8 weeks
before surgery saw a dramatic decrease in the overall complication rate in the smoking
cessation group, mainly from diminished wound infections. The longer a patient can
abstain from smoking before surgery, the greater the perioperative health benefit will be:
bronchociliary function improves within 2 to 3 days of cessation, and sputum volume
decreases to normal levels within about 2 weeks.
13. For patients scheduled for noncardiac surgery, what are guidelines for
perioperative cardiac evaluation?
An algorithmic approach to perioperative cardiac evaluation in patients who will undergo
noncardiac surgery requires assessment of a patient’s cardiac risks before surgery, taking into
account the urgency of surgery, the presence of active cardiac conditions, the invasiveness of
the planned surgery, the patient’s functional status, and the presence of clinical risk factors
for ischemic heart disease. Taken together, this algorithm underscores the importance of a
history focused on cardiac issues for all surgical patients.
14. What are the clinical risk factors for a major perioperative cardiac event?
The Revised Cardiac Risk Index (see Box 17-1) has six components: surgical risk, history of
ischemic heart disease, history of congestive heart failure, history of cerebrovascular disease,
preoperative treatment with insulin, and elevated preoperative serum creatinine. The

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 Preoperative Evaluation  117

patient is assigned one point for each of these risk factors, which are then translated into
percentage risks of perioperative major cardiac events such as myocardial infarction,
pulmonary edema, ventricular fibrillation, primary cardiac arrest, and complete heart block.
15. What constitutes the basic laboratory evaluation of coagulation status?
The basic laboratory evaluation includes platelet count, prothrombin time (PT), partial
thromboplastin time (PTT), and thrombin time. Thromboelastography is growing as a
methodology. Thromboelastography measures the combined function of platelets and
coagulation factors. The minimal number of normally functioning platelets to prevent
surgical bleeding is 50,000/mm3. Both the PT and PTT require about a 60% to 80% loss of
coagulation activity before becoming abnormal, but patients with smaller decreases in
function can still have significant surgical bleeding. Therefore the history is still very
important.
16. Are there special anesthetic considerations for surgical patients on warfarin?
Warfarin is a vitamin K antagonist and is used to prevent thrombosis and emboli. A patient
on warfarin is at high risk for intraoperative bleeding. Before stopping a patient’s warfarin,
it is important to know the indication for anticoagulation, the type and urgency of the
surgery, and the consequences of intraoperative bleeding. Patients who are at very high risk
of thromboembolism but nonetheless need to discontinue their anticoagulant (e.g.,
warfarin) in the perioperative setting are often bridged with low-molecular-weight heparin,
another much shorter-acting anticoagulant. Because warfarin has such a long half-life
(about 2.5 days) and heparin has such a short half-life (about 1.5 hours), a patient may be
instructed to stop warfarin 4 days before surgery and then, often as an inpatient, undergo
regular heparin injections up until a few hours before surgery. Once the surgery is completed
(and depending on the postoperative bleeding risk), the warfarin can be restarted.
17. What are considerations for patients with coronary stents?
Coronary stents, small metal mesh tubes that maintain patency of stenosed coronary
arteries, fall into two broad categories: bare metal stents and drug-eluting stents. The latter
slowly release a chemical that helps prevent endothelialization. An ongoing debate among
cardiologists is how long after stent placement a patient should remain anticoagulated. This
anticoagulation issue adds considerably to the complexity of recommending cardiac workups
for patients undergoing surgery. Patients with recent stent placement should not undergo
surgery right away because delays in anticoagulants are known to precipitate acute
myocardial infarctions.
18. Why is it necessary to evaluate patients for obstructive sleep apnea (OSA)
before surgery, and how should OSA be identified?
Patients with OSA are known to have increased postoperative morbidity. Identifying those
at risk remains a challenge despite an OSA diagnosis. Several screening tools (e.g.,
STOP-Bang, Berlin, and Flemons questionnaires) continue to challenge anesthesiologists
regarding appropriate postoperative disposition.

SUGGESTED READINGS
Practice Advisory for Preanesthesia Evaluation: An Updated Report by the American Society of
Anesthesiologists Task Force on Preanesthesia Evaluation, Anesthesiology 116(3):522–538, 2012.
Chung F, Yegneswaran B, Liao P, et al: Validation of the Berlin questionnaire and American Society of
Anesthesiologists checklist as screening tools for OSA in surgical patients, Anesthesiology 108:822–830,
2008.
Eagle KA, Berger PB, Calkins H, et al: ACC/AHA Guideline update for perioperative cardiac evaluation for
noncardiac surgery, Anesth Analg 94:1052–1064, 2002.
Gall B, Whalen FX, Schroder DR, et al: Identification of patients at risk for postoperative respiratory
complications using a preoperative OSA screening tool and post-anesthesia care assessment,
Anesthesiology 110:869–877, 2009.
Møller AM, Villebro N, Pedersen T, et al: 2002 Effect of preoperative smoking intervention on postoperative
complications: a randomised clinical trial, Lancet 359:114–117, 2002.
Sweitzer BJ: Preoperative evaluation and medication. In Miller RD, Pardo MC, editors: Basics of anesthesia,
ed 6, Philadelphia, 2011, Elsevier Saunders, pp 165–188.
Wijeysundera DM, Austin PC, Beattie WS, et al: Less is more. Outcomes and processes of care relate to
preoperative consultation, Arch Intern Med 170:1365–1374, 2010.

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