Preoperative Assessment and Preparation

Abstract

All patients presenting for surgical procedures under anesthesia benefit greatly from a thorough preanesthetic/preoperative assessment and targeted preparation, which serve to optimize any coexisting medical conditions and minimize the potential for complications. An increasing number of procedures are being performed on an outpatient basis, and the preoperative assessment and preparation often occurs in the surgeon’s office or even in the preoperative area on the day of surgery. In addition to identifying outstanding medical issues that may delay or lead to cancellation of their procedure on the scheduled date, the preoperative assessment is an excellent opportunity to prepare patients and families and to educate them about what to expect during and after administration of an anesthetic. For pediatric patients in particular, where the psychological needs of the patient differ depending on their age and the surgery and recovery involves and affects the entire family, the preoperative assessment has a crucial role in ensuring a smooth perioperative experience.

Appendices

Summary Points

For most children, general anesthesia is extremely safe, with a risk of dying at less than 1 in 250,000.

The goals of the preoperative evaluation are to identify and optimize active medical issues prior to the scheduled date of an operation.

ASA physical status score is a means of communication regarding a patient’s physical condition but does not necessarily correlate with operative risk.

The history should include a family history of serious ­anesthesia-related events and personal history of adverse reactions, such as difficult intubation, poor intravenous access, postoperative nausea/vomiting, or emergence delirium.

Management of reactive airways disease should be optimized preoperatively with the help of the primary care prov­iders and might include bronchodilator nebulizer treatments every 6 h for 48 h before the operation.

Loose teeth should be sought for and preferably removed at induction before attempted intubation to avoid foreign body aspiration.

Obese patients with sleep apnea can be difficult to intubate and often need to be monitored as an inpatient postoperatively.

Patients with an upper respiratory infection but no signs of systemic illness and normal lung sounds on auscultation are generally safe to proceed with general anesthesia.

“Innocent murmurs” are extremely common in children and in the absence of other symptoms do not require ­cardiology consultation or SBE prophylaxis.

Antibiotic SBE prophylaxis guidelines have changed ­considerably in the past few years and it is now only recommended in certain specific situations.

LQTS places the child at risk for torsades de pointes when exposed to certain medications.

GERD is very common but does not appear to increase the risk of aspiration if NPO guidelines are adhered to.

Management of blood sugar for patients with diabetes needs to be individualized and best coordinated with the patient’s endocrinologist ahead of time.

Most patients do not need “stress doses” of corticosteroids unless they have been on exogenous corticosteroids for a very long period of time or the planned operation is associated with significant physiologic stress.

Only infants and children at risk for anemia or scheduled for operations associated with significant blood loss should have a complete blood count performed preoperatively.

Premature infants and children with sickle cell disease should be transfused to a hemoglobin of 10 g/dL before an operation requiring a general anesthetic.

Editor’s Comments

We are fortunate to live in an era in which general anesthesia, especially for healthy children, is extraordinarily safe. In fact, because it involves more secure control of the airway, it is probably associated with fewer serious complications than moderate sedation. Nevertheless, we should not be complacent, but instead should take every case involving general anesthesia very seriously. This means a meticulous and systematic approach to preoperative preparation based on evidence-based protocols and strict attention to detail. Many institutions utilize physician extenders to perform the preoperative assessment of every patient according to strict guidelines. Children at our institution are evaluated by surgery APNs, unless they have significant risk factors for an anesthetic or surgical complication, in which case they are seen in the Anesthesiology Department by specially trained APNs or an anesthesiologist.

Allergies are obviously important to document, but it is also clear that the majority of reported allergies are erroneous or exaggerated. This is partly due to overly anxious parents who are quick to label their children with an allergy and clinicians who are afraid of being held liable for inducing an allergic reaction. Falsely reported reactions prevent some patients from ­getting the medications they need or force clinicians to administer inferior alternatives. Moreover, the science of allergy immunology is clearly still inadequate to help us sort out these very important questions. Until better tests or preventive medications become available, we have no choice but to continue taking a careful history and using the current approach, albeit characterized by somewhat excessive caution.

Healthy children should not be subjected to phlebotomy or medical imaging unless absolutely necessary. It is useful to have very specific guidelines with clear triggers for various proposed tests. To avoid a delay or last-minute cancellation, consult with an anesthesiologist well in advance of the scheduled date of the operation.