Preoperative Consultation 101

Risk Assessment & Optimization

Clinicians are often asked to examine patients before surgery. A medical advisor can be a primary care physician who sees patients at the surgeon's request or evaluates patients before considering surgical referral. The goal of evaluating healthy patients is to identify undetected diseases and risk factors that may increase surgical risk above baseline and suggest strategies to reduce this risk.

Main steps:

- Knowledge of the pathology that motivates the interventional procedure
- Knowledge of the medical, surgical and obstetrical history, of the treatments usually taken (nature, dosage) and detinition of the significant drug interferences requiring an adaptation (cf. Adaptation of treatments)
- Assessment of the allergic risk (see Allergic risk in anesthesia)
- Assessment of cardiovascular risk in non-cardiac surgery:

• Procedure-related risk: major (major vascular surgery .), intermediate (intraperitoneal, thoracic, orthopedic surgery..), minor (endoscopies, superficial surgery, cataract, ambulatory surgery...).
• Patient risk: functional evaluation by 7 main questions: angina, exertional and decubitus dyspnea, loss of consciousness, palpitations, lower limb edema, arteritis).
• Calculation of the Lee score (see Cardiovascular evaluation in non-cardiac surgery)

- Search for glycemic imbalance (HbA1c assay), cardiac autonomic neuropathy in diabetic patients (see Anesthesia and diabetes)

- Evaluation of the risk of difficult intubation (see Difficult intubation) and full stomach (see Anesthesia and full stomach)

- Assessment of the risk of postoperative nausea and vomiting (e.g. Apfel score) (see PONV in adults)

- Assessment of the risk of bleeding and transfusion (cf. patient blood management sparing strategy)

- Search for sleep apnea syndrome (STOP-BANG Score) (cf. Sleep apnea syndrome in adults)

- At the end of this first part of the consultation, the ASA score is define:

• Class I: patient in good health.
• Class II: patient with moderate impairment of a major function.
• Class III: patient with severe impairment of a major function that does not result in disability.
• Class IV: a patient with severe impairment of a major function that is permanently life threatening.
• Class V: a moribund patient whose life expectancy without surgery is less than 24 hours.
• Class VI: a patient declared brain dead whose organs are removed for transplantation.
• Suffix U: if the operation is performed as an emergency.

- Planning of the chosen anesthesia strategy and the required monitoring, possible transfusion (or transfusion sparing strategy), postoperative pain management, prevention of PONV, standard examinations (if necessary) and specialized examinations and advice (see Preoperative examinations)
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- Prescription of a possible premedication (cf. Premedication of the adult) and antibiotic prophylaxis (cf. Antibioprophylaxis).

Inform and Consent

- Discussion of risks, information, and consent of the patient on the chosen strategy
- Answers to questions
- A document with additional information can be given on this occasion

A step-by-step process

Clinicians are often asked to examine patients before surgery. A medical advisor can be a primary care physician who sees patients at the surgeon's request or evaluates patients before considering surgical referral. The goal of evaluating healthy patients is to identify undetected diseases and risk factors that may increase surgical risk above baseline and suggest strategies to reduce this risk.

Before the visit

• Preoperative questionnaire & chart review

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