What are the key elements of a pre-operative exam?

Key Elements of a Pre-operative Examination

A comprehensive pre-operative examination should focus on medical record review, patient interview, physical examination, and selective preoperative testing based on specific patient and surgical risk factors rather than routine testing for all patients. 1, 2

Medical Record Review

• Review previous medical records within 6 months of surgery (if available and medical history unchanged) 1
• Check for:
  • History of airway difficulties with previous anesthetics
  • Cardiovascular problems including hypertension
  • Congenital or acquired medical conditions
  • Review of previous sleep studies (if available) 1
  • Current medications, including dosages, herbal supplements, and nutritional supplements 1
  • History of substance use (alcohol, tobacco, illicit drugs) 1

Patient Interview

• Assess functional capacity and exercise tolerance 1
• Identify serious cardiac conditions:
  • Unstable coronary syndromes
  • Prior angina
  • Recent or past myocardial infarction
  • Decompensated heart failure
  • Significant arrhythmias
  • Severe valvular disease 1
• Screen for obstructive sleep apnea:
  • Snoring
  • Apneic episodes
  • Frequent arousals during sleep
  • Morning headaches
  • Daytime somnolence 1
• Identify barriers to communication (language, hearing impairment) 1
• Assess patient's ability to cooperate and position for surgery 1

Physical Examination

At minimum, a directed pre-anesthesia physical examination should include assessment of:

• Airway
• Lungs
• Heart 1

Additional important elements:

• Vital signs (including blood pressure in both arms)
• Carotid pulse contour and bruits
• Jugular venous pressure and pulsations
• Precordial palpation and auscultation
• Abdominal palpation
• Examination of extremities for edema and vascular integrity
• Confirmation of implanted pacemaker or ICD 1
• Neck circumference, tonsil size, and tongue volume (especially for OSA risk) 1

Selective Preoperative Testing

Tests should be ordered selectively based on specific patient factors and surgical risk, not routinely 1, 2, 3:

• Complete Blood Count (CBC): Indicated for patients with history of anemia, recent blood loss, hematologic disorders, anticipated significant blood loss, cardiovascular surgery, or elderly patients undergoing major surgery 2

• Coagulation Studies: Indicated for patients with bleeding disorders, renal dysfunction, liver dysfunction, anticoagulant use, and based on type/invasiveness of procedure 1, 2

• Renal Function and Electrolytes: Indicated for patients taking diuretics, ACE inhibitors, ARBs, known renal disease, or undergoing major surgery 2

• ECG: Indicated for patients with active cardiovascular signs/symptoms, known cardiovascular disease undergoing intermediate/high-risk surgery, or multiple risk factors undergoing vascular surgery 2

• Chest X-ray: Indicated only for patients with new or unstable cardiopulmonary signs/symptoms, or patients at risk of postoperative pulmonary complications if results would change management 2

• Type and Screen: Required for high blood loss risk procedures (cardiovascular surgery, major orthopedic procedures, neurosurgery, major vascular procedures) or when blood loss >500 ml is anticipated 2

Preoperative Medication Management

• Continue beta blockers for patients already on them (administer at least 24 hours before surgery) 2
• Evaluate anticoagulant management case-by-case 2
• Recommend smoking cessation at least 4 weeks before surgery 2
• Hold dietary supplements affecting bleeding risk (garlic, ginkgo) for 2 weeks before surgery 2

Common Pitfalls to Avoid

1. Ordering routine tests without specific indications increases costs and may lead to unnecessary interventions 3
2. Failing to review previous medical records when available
3. Neglecting to assess functional capacity, which correlates well with surgical risk 1
4. Overlooking medication reconciliation, including supplements and over-the-counter medications
5. Using phrases like "clear for surgery" rather than providing specific recommendations 1
6. Neglecting to communicate findings directly with the surgical team

Remember that the preoperative consultation may represent the first careful cardiovascular evaluation for some patients in years, making it a critical opportunity to identify previously undiagnosed conditions 1.