Presence of a beard
BMI > 26 kg/m2
Missing teeth
Age > 55
History of snoring
The second most common airway complication involves patient dentition. It is imperative to discuss with the patient if he/she has any dentures, loose teeth, caps, crowns or anything else that may increase the patient’s risk of dental injury or aspiration of a dislodged tooth or tooth fragment.
Cardiovascular
In evaluating the cardiovascular system , the main objective should be to decide whether a patient needs further cardiac testing (stress test) or intervention (cardiac catheterization or cardiac surgery) prior to elective surgery.
Patients should be asked about any history of shortness of breath, dyspnea, chest pain, chest tightness, edema, hypertension, myocardial infarction, cardiac surgery, use of anticoagulants, diuretics, antihypertensive medication, use of antibiotics before dental work, last echocardiogram, or stress test.
One should then determine a patient’s functional capacity (see table below). Studies have correlated better perioperative outcome with patients whose metabolic equivalent (MET) activity was greater than or equal to 4 METs (see Table 8.1).
Table 8.1
Energy requirements for various activities
1 MET | Eating, getting dressed, working at a desk |
2 METS | Showering, walking down eight steps |
3 METS | Walking on a flat surface for one or two blocks |
4 METS | Raking leaves, weeding or pushing a power mower |
5 METS | Walking 4 miles per hour, social dancing, washing car |
6 METS | Nine holes of golf carrying clubs, heavy carpentry, using push mower |
7 METS | Digging, spading soil, singles tennis, carrying 60 lb |
8 METS | Moving heavy furniture, jogging slowly, rapidly climbing stairs, carrying 20 lb upstairs |
9 METS | Bicycling at a moderate pace, sawing wood, slow jumping rope |
10 METS | Brisk swimming, bicycling uphill, walking briskly uphill, jogging at 6 MPH |
11 METS | Cross-country skiing, full court basketball |
12 METS | Running continuously at 8 MPH |
The revised ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation & Care for Noncardiac Surgery recommend the following stepwise approach to evaluating a patient’s cardiac status for patients undergoing noncardiac surgery:
Step 1:
Determine the urgency of the planned surgery
If the patient requires emergent surgery, then further cardiac assessment should not delay treatment and the patient should go directly to the operating room.
If surgery is not emergent, then proceed to Step 2.
Step 2:
Does the patient have an active cardiac condition or clinical risk factors?
Unstable or severe angina
Recent myocardial infarction (≤1 month before surgery)
Decompensated heart failure
Significant arrhythmias (high-grade AV block, symptomatic ventricular arrhythmias, atrial fibrillation with uncontrolled ventricular rate, symptomatic bradycardia)
Severe valvular disease (severe aortic stenosis: mean pressure gradient >40 mmHg, aortic valve area <1.0 cm2, or symptomatic)
If the patient has one or more of the above conditions, then the cardiac issue should be evaluated, clarified, and treated appropriately. This often involves postponing surgery.
If the patient does not have any of the above conditions, then proceed to Step 3.
Step 3:
Is the patient undergoing low-risk surgery?
Low-risk surgeries (reported cardiac risk <1 %) include endoscopic procedures, superficial procedures, cataract surgeries, breast surgeries, and most ambulatory surgeries
Since interventions based on cardiovascular testing are unlikely to alter management, these patients may proceed with the planned surgery.
If the patient is undergoing intermediate (intraperitoneal, intrathoracic, carotid endarterectomy, head/neck, orthopedic surgery) or high-risk surgery (aortic, major vascular, peripheral vascular surgery), then proceed to Step 4.
Step 4:
Does the patient have good functional capacity without symptoms?
If that patient has good functional capacity (≥4METS without symptoms, see Table 8.1), then it is appropriate to proceed with the planned surgery.
If the patient has poor functional capacity, then proceed to Step 5.
Step 5:
Patients with poor/unknown functional capacity
In these patients, the presence or absence of active clinical risk factors determines the need for further evaluation.
Pulmonary
Postoperative pulmonary complications may prolong the patient’s hospital stay by an average of 1–2 weeks. Therefore, it is important to review patient and procedure-related risk factors, perform a clinical evaluation, and recommend risk-reduction strategies to improve patient care and outcome (Table 8.2).
Table 8.2
Clinical risk factors for increased perioperative cardiac risk
Potential patient-related risk factors for perioperative pulmonary complications include:
Smoking
Poor general health status (ASA > 2)
Old age (>70)
Obesity
Chronic obstructive pulmonary disease
Reactive Airway Disease (Asthma)
Potential procedure-related risk factors include:
Surgery > 3 h
General anesthesia
The type of surgery
Use of pancuronium1
Clinical evaluation should encompass a thorough history (i.e., inquiring about shortness of breath, wheezing, chest pain, recent fever/chills, bronchitis, asthma, emphysema, history of pneumonia or lung surgery, use of steroids) and a physical exam (i.e., auscultation for decreased breath sounds, wheezes, rhonchi, prolonged expiratory phase). Once all of the information is gathered, risk-reduction strategies (Table 8.3) can be implemented to optimize patient care.
Table 8.3
Risk reduction strategies for pulmonary complications
Preoperative |
Smoking cessation (for at least 8 weeks) |
Treat airflow obstruction (patients with COPD or asthma) |
Prescribe antibiotics / postpone surgery in presence of respiratory infection |
Educate patients about lung-expansion maneuvers |
Intraoperative |
Limit surgical duration < 3 h |
Avoid pancuronium |
Consider laparoscopic surgical approach |
Postoperative |
Encourage incentive spirometry and deep breathing exercises |
Initiate CPAP (continuous positive airway pressure) when indicated |
Consider epidural analgesia/intercostal nerve blocks |
Hepatic and Gastrointestinal Disease
Hepatic disease can contribute to end-organ dysfunction (endocrine system, pulmonary edema, pulmonary hypertension, renal failure, and cardiomyopathy) and increase the risk during certain surgeries. Hepatic disease can also cause abnormal coagulation and altered drug pharmacokinetics.
Gastrointestinal diseases may increase the potential for aspiration, dehydration, electrolyte disturbances, and anemia. While screening for gastrointestinal disease, it is important to inquire about history of nausea, vomiting, heartburn, food regurgitation, diarrhea, bloody stools, hiatal hernia, gastric ulcers, viral hepatitis, and alcoholism.
Bleeding Disorders
Bleeding disorders may increase the risk of perioperative complications, and necessitate further preoperative evaluation and planning. Possible causes of bleeding may be due to disorders of coagulation factors (e.g., hemophilia, Von Willebrand’s disease), thrombocytopenia, leukemia, platelet disorders (e.g., Bernard–Soulier syndrome, uremia), certain medications (e.g., warfarin, heparin, clopidrogel), cancer, and liver disease.
Endocrine
Endocrinopathies may carry a high risk for morbidity and mortality. Patients should be assessed for any history of risk factors for diabetes mellitus.
Diabetic patients should be evaluated with regard to the type, duration, and severity of disease. The patient’s current therapy (diet, oral hypoglycemic drug, and/or insulin regimen) should be assessed, along with a fasting glucose and HbA1c to determine degree of control. All diabetics should be evaluated for the presence of coronary artery disease and hypertension. Additionally, a serum creatinine level may be drawn to assess the degree of nephropathy, if present. Most providers will avoid regional anesthesia techniques in diabetics with severe peripheral neuropathy. Typically, patients on insulin are instructed to take half their morning dose of insulin on the day of surgery. Diabetics should be scheduled for elective surgery earlier in the day to minimize the impact of prolonged fasting on their glucose management.
Perioperative mortality associated with pheochromocytoma and carcinoid syndrome can reach 50 % if undiagnosed. Thus, screening patients for any history of thyroid, parathyroid, adrenal, or pituitary disease, and carcinoid syndrome, may help reduce potential perioperative risks.
Renal
History of any kidney disorder holds importance during the preoperative evaluation since abnormal renal function may result in secondary physiologic imbalances, abnormal platelet function (impaired aggregation), anemia, electrolyte imbalances, peripheral neuropathies, and altered drug metabolism and excretion. Investigation of a patient’s history of renal insufficiency, renal failure, and dialysis dependence (including timing and frequency) should therefore be undertaken.
Neurologic
When screening a patient for neurologic disease , the anesthesiologist should elicit a history of seizures, convulsions, tremors, headaches, numbness or tingling of an extremity, nerve injuries, and multiple sclerosis. Performance of a neuraxial technique or a regional nerve block requires knowledge of any previous nerve injuries or deficits (and documentation if present).
Musculoskeletal
One should ascertain any history of low back pain, radicular pain, herniated disks and chronic pain managed with opioids. Patients should also be assessed for any history or signs of myopathies – as they may portend postoperative muscle weakness.
Physical Exam
A preoperative physical exam begins with noting the patient’s baseline vital signs. During the airway evaluation, first document the Mallampati score (see Chap. 9, Airway Evaluation and Management). Then be sure to note any gross external features such as facial trauma, prominent incisors, a beard or moustache, a large tongue, neck masses, tracheal deviation, or if the patient is edentulous – all factors which could contribute to difficult mask ventilation or intubation. Note any possible airway obstruction (i.e., peritonsillar abscess, trauma) and limited neck mobility. The cardiopulmonary exam includes assessment of rate and rhythm, murmurs, wheezing, rhonchi, stridor (inspiratory versus expiratory), peripheral pulses, and baseline pulse oximetry saturation. Gastrointestinal exam includes looking for signs of ascites, abdominal distension, and guarding. Musculoskeletal exam may include neck range of motion, scoliosis, and assessment of pectus excavatum/carinatum. Finally, a neurologic exam may include an assessment of baseline muscle strength, mental status and any signs of preexisting nerve injury.
Medications/Allergies
The generic name of all medications with the route, dosage, and timing (including time of last dose) should be noted. In some cases, it is helpful to include the length of time the patient has been taking a given medication – particularly opioids as chronic use may lead to higher perioperative opioid requirements. Additionally, long-term use of steroids may result in adrenal insufficiency and steroid supplementation during surgery may be indicated.
A medication history should also encompass any over-the-counter or alternative medicines (i.e., herbal medications). This is important because many supplements have clinically important side effects that may manifest during anesthesia (e.g., ginko and garlic both potentiate anticoagulant medications, St. John’s Wort can prolong anesthesia, and Ephedra may cause dysrhythmias).
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