Chapter 10 Preoperative Evaluation and Medication
1. What is the purpose of the preanesthetic visit before the day of surgery?
2. How does the anesthesiologist classify a patient’s physical status?
Comorbidities impacting administration of anesthesia
6. What are the guidelines for cardiovascular evaluation for patients having noncardiac surgery?
7. How long does the patient need to wait after revascularization to undergo elective noncardiac surgery?
8. Should aspirin be continued perioperatively?
9. What can happen if aspirin is stopped abruptly?
10. What percentage of patients with compensated versus decompensated heart failure will have perioperative cardiac complications?
11. What are the main types of heart failure?
12. What are the common causes of systolic and diastolic dysfunction?
13. What finding on an ECG would suggest diastolic dysfunction?
14. For patients with heart failure, which symptoms should prompt echocardiographic evaluation preoperatively?
15. What further evaluation does a patient with heart failure symptoms at rest (decompensated failure or Class IV) need beyond an echocardiogram?
16. Is there a benefit of routine perioperative evaluation of left ventricular (LV) function before surgery?
17. What are the recommendations for preoperative noninvasive evaluation of LV function?
18. Are all cardiac murmurs associated with valvular pathology?
19. Which cardiac murmurs are always pathologic?
20. What are the clinical clues that suggest a patient may have valvular disease?
21. Which planned anesthetics should prompt the anesthesiologist to want an echocardiogram before proceeding with an anesthetic in a patient with a cardiac murmur?
22. When is an echocardiogram indicated in an asymptomatic patient with a cardiac murmur?
23. Are regurgitant or stenotic valvular lesions better tolerated perioperatively?
24. Does aortic stenosis and aortic sclerosis have similar hemodynamic manifestations?
25. Should patients with valvular abnormalities receive antibiotic prophylaxis to prevent infective endocarditis?
26. Which other conditions need antibiotic prophylaxis against infective endocarditis?
27. Should patients undergoing genitourinary (GU) and gastrointestinal (GI) tract procedures take antibiotic prophylaxis to prevent infective endocarditis?
28. For patients meeting criteria for prophylaxis against infective endocarditis, for which procedures is prophylaxis recommended?
29. What conditions are typically associated with a pacemaker and implantable cardioverter-defibrillator (ICD) placement?
30. How should the ICD be managed in the surgical patient?
31. Will a magnet disable an ICD?
32. Which comorbidities are hypertensive patients at risk of?
33. When should surgery be delayed due to elevated blood pressure (BP)? What is severe hypertension?
34. What is the preoperative BP goal for hypertensive patients?
35. Is there a risk in normalizing BP in hypertensive patients?
36. What are predictors of postoperative pulmonary complications?
37. Is chronic obstructive pulmonary disease (COPD) the greatest risk factor for postoperative pulmonary complications?
38. Does well-controlled asthma increase perioperative complications?
39. How can the risk of bronchospasm after tracheal intubation be decreased in patients with obstructive airway disease?
40. If steroids are given, how much steroid should be administered preoperatively to a patient with persistent airway obstruction?
41. Which types of anesthesia are associated with a greater risk of postoperative pulmonary complications (PPC)?
42. Does preoperative testing predict the risk of PPC?
43. Which maneuvers can reduce PPC rates?
44. What is obstructive sleep apnea (OSA)?
45. Which symptoms and risk factors are associated with OSA?
46. What components of the patient’s history or physical examination can identify those at risk of OSA?
47. Which comorbidities are associated with OSA?
48. What impact does OSA have for anesthesia?
49. Should patients having anesthesia bring their continuous positive airway pressure (CPAP) devices to the hospital?
50. What are the American Society of Anesthesiologists’ (ASA) published recommendations for perioperative care of patients with OSA?
51. What are the most common causes of dyspnea?
52. How should dyspnea be evaluated?
53. Is renal insufficiency a risk factor for perioperative complications?
54. When should a patient with renal insufficiency receive dialysis before surgery?
55. Must chronic hyperkalemia be corrected in a patient with renal insufficiency?
56. Does radiocontrast medium worsen renal function in normal patients?
57. Can the risk of renal injury be reduced in patients receiving radiocontrast medium?
58. What are the goals of perioperative glucose control in diabetic patients?
59. If a diabetic patient has an Hb A1c of 12 on the day of surgery with a glucose level of 350 g/dL, should the surgery be cancelled?
60. What body mass index (BMI) defines extreme obesity?
61. Which comorbidities are associated with obesity?
62. Does anemia predict perioperative morbidity and mortality?
63. Does a patient with anemia require further evaluation to identify its cause?
64. What perioperative concerns surround a pregnant patient who needs a nonobstetric
65. Are elderly patients at a higher risk for hospital admission after ambulatory surgery?
66. How does a patient’s do not resuscitate (DNR) status transfer from the hospital ward to the operating room?
Testing
69. Is preoperative testing indicated for every patient?
70. When should preoperative tests be ordered?
71. Should all patients of a certain age receive a preoperative electrocardiogram (ECG)?
72. Do preoperative ECGs or chest radiographs predict postoperative complications?
73. What are the recommendations for obtaining a preoperative ECG?
74. Do all females of childbearing years require a β-human chorionic gonadotropin (β-hCG) assay prior to surgery?
75. Which types of preoperative tests are useful when evaluating patients with severe
comorbidities and undergoing intermediate-high risk procedures?
76. What are the minimal recommendations for testing before anesthesia?
Medications
77. Should all medications be continued perioperatively?
78. Should β-adrenergic blockers (BB) be continued preoperatively?
79. Are there medications that can lower cardiac risk for high-risk patients scheduled for elective noncardiac surgery?
80. What are the benefits of statins perioperatively?
81. Can statins be abruptly stopped?
82. Can neuraxial or peripheral anesthesia be performed on a patient taking aspirin or
83. Should psychiatric medications be continued preoperatively?
84. Should angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) be continued preoperatively?
85. When should low-molecular-weight heparin (LMWH) be discontinued before surgery?
86. How many days before surgery should warfarin be stopped?
87. What should be done if the international normalized ratio (INR) is elevated near the day of surgery?
88. When should patients on warfarin be bridged with LMWH before surgery?
89. In which patients is LMWH contraindicated?
90. How should type 1 and type 2 diabetics be managed preoperatively?
91. Should ultra–long-acting insulin such as glargine be continued on the day of surgery?
92. Does metformin need to be discontinued before the day of surgery?
93. Should oral hypoglycemic drugs be withheld on the day of surgery?
94. Which medications should be continued on the day of surgery?
95. Which medications should be discontinued for surgery?
96. Which herbal medication should not be discontinued abruptly before surgery?
97. Is neuraxial anesthesia contraindicated in patients taking herbal medications?
98. Should monoamine oxidase inhibitors (MAOIs) be discontinued before surgery?
99. Should narcotics, anxiolytics, or nicotine replacement be discontinued before surgery?
100. Should patients taking oral steroids take the steroid on the day of surgery?
101. How much cortisol does a patient typically produce a day?
102. Which patients are at risk for adrenal insufficiency?
103. What risks are associated with high-dose steroids?
104. How should perioperative glucocorticoids be dosed for a patient on chronic steroids?
105. How should anxious patients be premedicated before surgery?
106. What medications can be offered preoperatively to patients with a history of severe postoperative nausea and vomiting (PONV)?
107. Who is at risk for pulmonary aspiration, and how should they be premedicated?
Answers*
1. The purpose of the visit is to interview the patient or guardian and establish a medical, medication, and anesthesia history, and to determine the patient’s functional capacity. At this visit, the anesthesiologist performs a physical examination focusing on the airway, vital signs, and cardiovascular, pulmonary, and neurologic systems; reviews previous diagnostic tests, consultations, and laboratory results; assigns an ASA-physical status (see question 2); and determines whether further tests are necessary before surgery. An anesthetic plan is formulated and discussed with the responsible adult before informed consent is obtained. Medical therapies are optimized, fasting instructions are provided, and preoperative medication recommendations are given. (165-166, Figure 13-1)
2. The American Society of Anesthesiologists (ASA) Physical Status Classification ranges from ASA 1 to ASA 6. A patient who is classified as ASA 1 is healthy, without disease. ASA 2 is for patients with mild systemic disease that is well controlled. ASA 3 refers to patients with systemic disease sufficiently severe to limit daily activity (renal failure on dialysis or class 2 heart failure). ASA 4 is for patients with a severe disease that is a constant threat to life and seriously limits daily activities (acute myocardial infarction or respiratory failure requiring mechanical ventilation). ASA 5 refers to moribund patients likely to die in less than 24 hours with or without surgery. ASA 6 is reserved for brain-dead patients who are organ donors. The letter E is added to a classification if the surgical procedure is an emergency. (Table 13-1)
History and physical examination
3. A patient’s functional capacity is measured in metabolic equivalents (MET). One MET is equivalent to the consumption of 3.5 mL O2/kg/min. A patient able to eat, get dressed, and work at a computer has a MET of 1. A patient who can walk two blocks has a MET of 3. Climbing one flight of stairs equals a MET of 5; a MET of 10 is running or jogging briskly. A MET of 12 is achieved with running rapidly for long distances. A patient’s functional capacity predicts outcome, perioperative complications, and indicates the need for further evaluation. (166, Table 13-2)
4. The airway examination is performed to assist in predicting the ease of hand mask ventilation and endotracheal intubation of the patient. If difficult airway management is predicted, then necessary equipment can be set up and skilled personnel alerted and available on the day of surgery. (Figure 13-2, Table 13-3)
5. During the airway examination the following are assessed: the condition of the teeth, the ability of the patient to advance or protrude the mandibular incisors; the tongue size; visibility of the uvula, tonsils, soft palate, or hard palate only (Mallampati classification I-IV); the presence of facial hair; the thyromental distance; and the length, thickness, and range of motion of the neck. (Figure 13-2, Table 13-3)
Comorbidities impacting administration of anesthesia
6. The American College of Cardiology/American Heart Association (ACC/AHA) guidelines have decreased the number of recommendations for testing and revascularization. The approach to this algorithm should stop at the first step that applies to the patient.
If the surgery is not an emergency, then the algorithm is as follows:
Step 5 (poor functional capacity): if the patient has poor functional capacity and needs intermediate-risk or vascular surgery, then important clinical predictors (not increased age or elevated blood pressure) are used to determine if more testing is necessary. The five important clinical predictors based on the revised cardiac risk index (RCRI) include ischemic heart disease, compensated or prior heart failure, cerebrovascular disease (stroke, transient ischemic attack), diabetes mellitus, and renal insufficiency. If no clinical predictors are present, the patient may proceed to surgery without further testing. If one or more clinical predictors are present, the patient may proceed to surgery with heart rate control, or noninvasive testing may be considered before surgery if it will change management. (166, Figure 13-3)
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