History and Pre-operative

Evaluation of Patients
Undergone Surgery
Michota FA, Frost SD. The preoperative evaluation: use the history and physical rather than
routine testing. Cleve Clin J Med. 2004 Jan;71(1):63-70.

Pembimbing: Diah Asri Wulandari, dr., Sp. A (K)

Disusun oleh:
Jamarudin (160121170001)
Kalia Labitta (160121170004)

DEPARTEMEN ILMU KESEHATAN ANAK

FAKULTAS KEDOKTERAN
UNIVERSITAS PADJADJARAN
• The history and physical examination, rather than
routine laboratory, cardiovascular, and pulmonary
testing, are the most important components of the
preoperative evaluation. The history should include a
complete review of systems (especially cardiovascular
and pulmonary), medication history, allergies, surgical
and anesthetic history, and functional status.
THE BASICS OF THE PREOPERATIVE EVALUATION

• The basics of the preoperative evaluation are a

comprehensive history, a detailed physical
examination, and selected laboratory tests.
Pre-Operative History
The pre-operative history follows the same structure as typical
history taking, with the addition of some anaesthetic and surgery
specific topics.

1. History of the Presenting Complaint

A brief history of why the patient first attended and

what procedure they have subsequently been scheduled
for. One should also confirm the side on which the
procedure will be performed (if applicable)
2. Past Medical History (PMH)
A full PMH is required, with the following specifically asked about:
• Cardiovascular disease (including hypertension and exercise tolerance) 
The risk of an acute cardiac event is increased during anaesthesia

• Respiratory disease, as adequate planned oxygenation is essential in

reducing the risk of acute ischaemic events in the peri-operative period

• Renal disease, such as anaemia, coagulopathy, biochemical disturbances

can increase the incidence of surgical complications.
• Blood loss or IV contrast given during some procedures can cause significant
renal dysfunction, so extra care may be taken.

• Endocrine disease, specifically diabetes mellitus and thyroid disease

• Many medications often require specific changes to be made in the peri-
operative period
3. Past Surgical History
• What, when and why the patient had any previous
operations.

4. Surgical and anesthetic history

• Any issues involving the past anaesthesia before
• Any past nausea or vomiting
• Patients with a history of bleeding complications should be
carefully assessed for coagulation disorders.
• Reactions to anesthetics by the patient or family members
should raise concerns about susceptibility to malignant
hyperthermia.
• Patients with malignant hyperthermia susceptibility require
an anesthesia consultation, appropriate preparation of the
operating room, and adequate equipment and expertise in
the event of a malignant hyperthermic reaction.
5. Drug History
• A full drug history is required, as some medications require
stopping or altering prior to surgery.

• Particularly allergies to rubber products and to foods associated

with latex reactions.

• Patients whose risk of bleeding exceeds their risk of thrombosis

should refrain from preoperative use of aspirin for 7 to 10 days,
nonselective nonsteroidal anti-inflammatory drugs for 3 to 5 days,
and thienopyridines (such as clopidogrel) for a full 2 weeks before
surgery.

• COX-2 inhibitors do not potentiate bleeding and may be continued

until surgery. However, caution should be exercised after surgery
because of a theoretical increase in risk of cardiovascular events.
6.Family History
• An important condition to ask about is malignant
hyperpyrexia* (also known as malignant
hyperthermia), yet any other adverse reactions in
surgery of immediate family members should also be
documented.

• *An autosomal dominant condition that

characteristically leads initially to muscle rigidity
(despite neuromuscular blockade) followed by a rise in
temperature (requires senior input and support if
present)

7. Social History
• Ensure to ask the patient about smoking history and
alcohol intake and their exercise tolerence.
Pre-Operative Examination
• In the pre-operative examination, two distinct examinations
are performed;
▫ the general examination (to identify any underlying pathology)
and
▫ the airway examination (to predict the difficulty of
intubation). If appropriate, the area relevant to the operation
can also be examined.

• All patients should receive a thorough cardiovascular and

pulmonary examination and should be asked about chronic
or recent infections.

• Unexpected abnormal findings on the physical examination

should be fully characterized and investigated before
elective surgery.

• An anaesthetic exam, including an airway assessment, will

also be performed by the anaesthetist prior to any surgery.
Pre-Operative Investigations
• The nature of the exact investigations required
depends on a number of factors, including co-
morbidities, age and the seriousness of the procedure.

• Each specific hospital is likely to provide local

guidelines, however it is useful to understand the tests
than could be done pre-operatively and have an
appreciation as to why each may be requested.
BLOOD TESTS
1. Full Blood Count (FBC)
• Most patients will get a full blood count  if there is undiagnosed
anaemia or thrombocytopenia, as this requires correction pre-
operatively to reduce the risk of cardiovascular events.

2. Urea & Electrolytes (U&Es)

• To assess the baseline renal function of the kidneys, indicate potential
co-morbid status and help inform any potential IV fluid management
intra-operatively

3. Liver Function Tests (LFTs)

• Important in the assessing liver metabolism and synthesising function,
useful for peri-operative management
• if there is suspicion of liver impairment, LFTs may help direct medication
choice and dosing

4. Clotting Screen
• Any indication of deranged coagulation, such as iatrogenic causes (e.g.
warfarin), inherited coagulopathies (e.g haemophilia A/B), or liver or
renal impairment, will need identifying and correcting before surgery
IMAGING
1. Electrocardiogram (ECG)
• An ECG is often performed in individuals with a history of
cardiovascular disease or for those undergoing major surgery. It
can indicate any underlying cardiac pathology and provide a
baseline if there are post-operative signs of cardiac ischaemia.

2. Chest X-Ray
• A Chest X-ray (CXR) should be used only when absolutely necessary
and should not be performed routinely (Fig. 1). Local guidelines
should be available to aid decision-making and indications may
include:
▫ Respiratory illness who have not had a CXR within 12 months
▫ New cardiorespiratory symptoms
▫ Recent travel from areas with endemic tuberculosis
▫ Significant smoking histor
ASSESSING CARDIOVASCULAR RISK
• Cardiac risk assessment is a critical component of the
preoperative evaluation.

• In actual practice, physicians should apply an overall risk

equation defined by the patient’s disease (patient risk) and
the degree of surgical stress (procedural risk).

• Lee et al performed a prospective cohort study to try to

simplify the preoperative assessment of cardiac risk. Major
cardiac complications were defined as myocardial infarction,
pulmonary edema, ventricular fibrillation, primary cardiac
arrest, or complete heart block.
• The new ACC/AHA guidelines offer a shortcut to the decision
regarding noninvasive cardiac stress testing that emphasizes
the patient’s functional status (TABLE 2).

• In general, the history and physical examination usually

determine the patient’s risk profile. If the risk profile is
unclear, then noninvasive cardiac stress testing should be
performed.

• Noninvasive cardiac stress testing should also be performed if

the patient is thought to be at high risk, to further stratify the
risk.

• Most patients whose risk profile is unclear will need a

pharmacologic stress test.

• All patients with cardiovascular risk factors should receive

beta-blockers perioperatively unless strongly contraindicated.
PULMONARY RISK
• The most important predictor of pulmonary risk is the surgical site,
and that risk increases as the incision approaches the diaphragm.

• The most important modifiable risk factor is smoking. Although

smoking cessation leads to beneficial physiologic effects in only 48
hours, the risk for postoperative pulmonary complications declines
only after 8 weeks of preoperative cessation.

• The role for preoperative pulmonary function testing remains

uncertain. No data suggest that spirometry identifies a high-risk
group that would not otherwise be predicted by the history and
physical examination.
Preoperative pulmonary risk-reduction
strategies

• Encourage smoking cessation for at least 8 weeks

preoperatively
• Treat airflow obstruction in patients with chronic
obstructive pulmonary disease or asthma
• Give antibiotics and delay surgery if pulmonary
infection is present
• Begin patient education regarding lung-expansion
maneuvers
ADDITIONAL RECOMMENDATIONS
• Each surgical patient should be assessed for risk
for surgical site infections, bacterial
endocarditis, and venous thromboembolism.

• Depending on the findings, recommendations

should be made regarding appropriate
prophylaxis against these conditions.