What is the recommended pre-operative evaluation for patients undergoing general anesthesia?

From the Guidelines

The recommended pre-operative evaluation for patients undergoing general anesthesia includes a comprehensive history and physical examination, laboratory testing based on individual risk factors, and assessment of the airway and cardiovascular status, with patients fasting for at least 6 hours for solid food and 2 hours for clear liquids before surgery to reduce aspiration risk, as supported by the most recent evidence 1. This evaluation should begin with a detailed medical history covering previous anesthetic experiences, medication use (including over-the-counter drugs and supplements), allergies, and existing medical conditions.

• Key aspects of the history include:
  • Previous anesthetic experiences
  • Medication use, including over-the-counter drugs and supplements
  • Allergies
  • Existing medical conditions Laboratory tests should be ordered selectively based on the patient's health status and planned procedure, typically including complete blood count, basic metabolic panel, coagulation studies, and electrocardiogram for patients with cardiovascular risk factors, as recommended by recent guidelines 1.
• Airway assessment using the Mallampati classification, thyromental distance, and neck mobility is crucial to anticipate difficult intubation. Medication management is important - most antihypertensives should be continued until surgery, while anticoagulants may need to be discontinued (warfarin 5 days prior, DOACs 48-72 hours prior depending on renal function) 1.
• Diabetic patients require blood glucose monitoring and insulin adjustment, with capillary blood glucose and ketone monitoring immediately accessible in every location where patients are anaesthetised, and blood glucose measured at least hourly in patients with treated diabetes 1. This comprehensive approach helps identify potential complications, allows for appropriate anesthetic planning, and ultimately improves patient safety during general anesthesia, in line with the latest recommendations for standards of monitoring during anaesthesia and recovery 1.
• The use of quantitative neuromuscular monitoring and processed electroencephalogram (pEEG) monitoring should be considered when necessary, as outlined in recent guidelines 1. Overall, the goal of pre-operative evaluation is to minimize risks and ensure the best possible outcomes for patients undergoing general anesthesia, prioritizing morbidity, mortality, and quality of life, as emphasized by the most recent and highest quality studies 1.

From the FDA Drug Label

Adults and Pediatrics Sedation guidelines recommend a careful presedation history to determine how a patient’s underlying medical conditions or concomitant medications might affect their response to sedation/analgesia as well as a physical examination including a focused examination of the airway for abnormalities.

The recommended pre-operative evaluation for patients undergoing general anesthesia includes:

• A careful presedation history to assess the patient's underlying medical conditions and concomitant medications
• A physical examination, including a focused examination of the airway for abnormalities
• Appropriate presedation fasting
• Titration to effect with multiple small doses to minimize the potential for oversedation
• Monitoring by a dedicated individual, other than the practitioner performing the procedure, for deeply sedated patients 2 2

From the Research

Pre-operative Evaluation for General Anesthesia

The pre-operative evaluation for patients undergoing general anesthesia is a crucial step in ensuring the safety and quality of care. The following are key components of this evaluation:

• A thorough clinical pre-operative assessment of the patient, which is more important than routine pre-operative tests 3
• Clinical history, pre-operative questionnaires, physical examination, and individual risk-assessment 3, 4
• Laboratory investigations should be ordered only when indicated by the patient's medical status, drug therapy, or the nature of the proposed procedure 3, 5
• Routine pre-operative evaluation will vary among patients, depending on age and general health 6
• The evaluation should focus on risk factors for cardiac and pulmonary complications and determine the patient's functional capacity 5

Importance of Pre-operative Evaluation

The pre-operative evaluation is essential in:

• Reducing the patient's surgical and anesthetic perioperative morbidity or mortality 5
• Returning the patient to desirable functioning as quickly as possible 5
• Identifying correctable medical abnormalities and understanding the residual risk 6
• Minimizing the risk of complications while providing the safest care available for the patient 4

Special Considerations

• Patients with hypertension require a dual focus on establishing an appropriate level of blood pressure control before anesthesia and surgery, and assessing the degree of cardiovascular impairment 7
• Close communication between clinician and anesthesiologist is crucial in ensuring the patient's safety 7
• The pre-operative preparation involves procedures that are implemented based on the nature of the expected operation as well as the findings of the diagnostic workup and the pre-operative evaluation 5