Introduction
Every surgery starts before the patient even arrives to the operating room. As doctors, we know that what happens in the days or weeks before surgery can have a huge effect on what happens during and after the procedure. Filling these forms is only part of the pre-operative assessment. It’s a really critical clinical checkpoint where we may uncover hazards, stabilize co-morbidities, and make sure that the anesthetic and surgical plans are safe and work.
This article will show you a well-organized and useful way to perform the pre-op exam, with a focus on clinical nuance, red flags, and making decisions based on evidence. If you are an anesthesiologist, surgeon, or doctor who works in perioperative care, this article gives you a useful, risk-based framework.
Why Pre-Operative Assessment Is More Important Than Ever
A good pre-op evaluation involves more than just check to see if you’re healthy. It can:
- Try to figure out the risk before, during, and after operation.
- Help pick the best anesthetic for surgery
- Stop cancellations that don’t need to happen.
- Reduce the chance of problems and mortality after surgery
Because more patients are getting older and sick with more than one disease, the choices we make before surgery have more and more of an impact. The good news is? This is one of the best things we can do to help if we do it right.
The Key Components of a Comprehensive Pre-Operative Assessment
Let’s go over each crucial area of the assessment, utilizing both our professional judgment and what we think is best for the patient.
1. Pre-Operative History: Not Just the Basics
The Presenting Problem and Planned Procedure
Start with the “why” and the “what”:
- What is the rationale for the surgery on the patient?
- What kind of surgery is planned, and which side (if there is one) will it be on?
- Consider how the underlying illness might alter how the anesthetic is planned. For instance, neck masses, past head and neck surgery, or airway tumors could mean that intubation will be hard.
Systemic Past Medical History
A structured PMH review should focus on identifying anaesthesia-related co-morbidities:
- Cardiovascular System: Heart failure, excessive blood pressure, arrhythmias, or ischemic heart disease. Ask about exercise tolerance, angina, orthopnea, or syncope. Think about functional tests if the patient is going to have major surgery.
- Respiratory Health: COPD, asthma, and OSA (use the STOP-BANG criterion as a filter). Ask the patient if they can comfortably rest or if they feel sleepy during the day.
- Renal Illness: Know the patient’s normal eGFR and the medications that can damage the kidneys.
- Endocrine Issues: Diabetes (check HbA1c), too much or too little of the hormone that controls the thyroid.
- Gastroesophageal Reflux Disease (GERD): Often underreported, yet important for figuring out the risk of aspiration.
- Hematological Problems: Think about sickle cell and other hemoglobinopathies that haven’t been diagnosed yet in communities that are at risk.
High-Risk Considerations
- Pregnancy (testing is essential for women who can get pregnant)
- Bleeding Disorders (personal or family history, anticoagulants)
- Immunocompromise due to illness or therapy
History of Surgery and Anesthesia
- Previous surgeries may suggest the likelihood of adhesions, anatomical alterations, or heightened complexity.
- Please write down any negative reactions to anesthesia, like malignant hyperthermia, trouble with intubation, or PONV.
Review of Medications and Allergies
- Find out which medicines need to be held back or bridged. For example, ACE inhibitors, anticoagulants, and antiplatelets.
- Don’t forget to take vitamins and over-the-counter medications.
- Be sure to put down both drug and non-drug allergies clearly.
Social History and Support Systems
- Using drugs, drinking, and smoking for fun (important for the danger of withdrawal)
- Do you have any troubles with language? You may need an interpreter when you provide your consent.
- Is there someone at home to take care of you once you leave the hospital? This has an effect on how long someone stays and how they plan to leave.
2. Physical Exam: A Focused, Forward-Looking General Clinical Exam
Watch for signs of:
- Signs of decompensation or heart murmurs that haven’t been found yet
- Trouble breathing
- Abdominal pathology (e.g., hepatomegaly, ascites)
These results might need more testing or push back elective surgery.
Airway Assessment
A formal airway exam is very important and usually includes:
- Score on the Mallampati test
- How far apart the thyroid and the mind are
- Opening the mouth
- Moving the neck
- Condition of the teeth
These considerations influence both the intubation technique and the appropriateness of awake fiberoptic or regional anesthesia.
3. Assigning the ASA Physical Status Classification
Before surgery, the ASA classification is still the best way to tell how healthy someone is. Yes, it’s a matter of opinion, but it’s important.
What does ASA mean? Mortality rate by grade (%)
- I. Healthy patient: 0.1%
- II. Mild systemic disease: 0.2%
- III. Severe systemic disease: 1.8%
- IV. Systemic sickness that could kill you: 7.8%
- V. Dying, not expected to live without surgery: 9.4%
- E Emergency procedure —
If you know what the ASA score signifies, you can make better choices about triage, anesthetic planning, and post-op care.
4. Pre-Operative Investigations: What to Order and Why
Not every patient needs a full panel. Base studies on the person’s risk, other health problems, and the size of the procedure.
Blood Tests
- FBC—Anemia or thrombocytopenia can change how blood is given.
- U&Es—Help with managing fluids and medicine doses, especially opioids.
- LFTs—if you think your liver isn’t working right; they change how medications are broken down in the body.
- HbA1c or TFTs—if you have diabetes or thyroid problems.
- Clotting screen—This is especially important for patients who use blood thinners or have liver disease.
- Viral Profile
Group & Save or Cross-Match
- G&S: For procedures where there isn’t a lot of blood loss and a transfusion is possible but not likely.
- Cross-Match: Get ready ahead of time for surgeries that are really risky or that lose a lot of blood.
Cardiac Workup and ECG
Indications:
- Age above 60
- Heart disease that is known
- Large operations
If a patient has signs of heart disease or is at high risk for it, they should think about getting extra tests done on their heart, such as an echo, a stress test, or an MPS.
Respiratory Investigations
- Spirometry: To measure the current baseline and risk of deterioration in individuals with COPD or asthma.
- CXR: Only when clinically indicated (e.g., active infection, unexplained symptoms)
Other Important Investigations
- MRSA screening: Most places do this; if it’s positive, get rid of it.
- Urinalysis: Especially before surgery on the urinary tract.
- Cardiopulmonary Exercise Testing (CPET): For patients who need a lot of surgery or are almost functional. Gives VO2 max and anaerobic threshold to help you figure out how risky something is.
Key Takeaways for Clinicians
- The pre-op assessment is more than just a formality; it’s a really significant way to minimize risk.
- A well-planned approach that includes a targeted history, a focused examination, and therapeutically motivated investigations can considerably minimize the risk of problems during and after surgery.
- Look out for the signs that people typically miss: risk factors for OSA, over-the-counter drugs that aren’t reported, and social support for recovery.
- Make a detailed plan for the time before and after surgery with people from other teams, such as anesthetists, surgeons, internists, and even social workers.
Conclusion of Pre-operative assessment
In conclusion of pre-operative assessment, you can help make surgery safer before the first cut.
Getting ready for surgery is always the first step in the story. The way we act before surgery typically determines how the story ends: with complications or a smooth recovery.
What have you done to decrease the chance of complications during your pre-op evaluations? Let’s raise the bar by sharing what we know.
