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Chapter 6: Preoperative Evaluation

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What is the single most important test to perform to ascertain a patient’s risk assessment and preparation prior to a surgical procedure?

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(A) History and physical exam

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(B) Serum electrolytes

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(C) Chest x-ray

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(D) Electrocardiogram

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(E) Stress test

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(A) A history and physical is diagnostic in 75–90% of patients. Diagnostically, the history is three times more productive than the physical examination and 11 times more effective than routine laboratory tests. Furthermore, “routine” preoperative testing is not cost-effective, may result in morbidity to the patient from further workup of false-positive results, and is less predictive of perioperative morbidity than the American Society of Anesthesiologists (ASA) status or American Heart Association (AHA)/American College of Cardiology (ACC) guidelines for surgical risk.

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The preoperative medical history should include previous exposure to anesthesia, allergies including medication and foods, and family history of problems with anesthesia or surgical procedures. A detailed list of current medications should be fully explored for potential interactions, and patients should be counseled to continue medications up to the morning of surgery.

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Review of systems with identification of comorbidities (history of myocardial infarction [MI], syncope, angina, anemia, orthostatic intolerance, pulmonary edema, valvular disease, hepatic and renal failure, diabetes) reveals areas for further testing. A baseline level of activity should be ascertained. Patients who are unable to achieve at least 4 METs (metabolic equivalents) of activity, which is defined as being able to climb two flights of stairs without stopping, or walking briskly for up to four city blocks, and those with BMI >35 are particularly prone to comorbidities that may seem unusual at an early age, including sleep apnea and ischemic heart disease.

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The physical exam should be focused on the neurologic, cardiac, pulmonary, hepatobiliary, and renal systems.

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BIBLIOGRAPHY

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Dorian RS. Anesthesia of the surgical patient. In: Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE eds. Schwartz’s Principles of Surgery 9th ed. New York, NY: McGraw-Hill; 2010:Chapter 47.

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Neumayer L, Vargo D. Principles of preoperative and operative surgery. In: Sabiston Textbook of Surgery 18th ed. Philadelphia, PA: Elsevier Saunders; 2008:251–279.

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Shammash JB, Ghali WA. Preoperative assessment and perioperative management of the patient with nonischemic heart disease. Med Clin North Am 2003;87(1):137–152.

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Which of the following is a predictor of difficult intubation?

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(A) Prior neck injury with normal mobility

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(B) Interincisor distance >4 cm

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(C) Large underbite

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