Preoperative patient assessment

Chart Review

• A pre-op template can be found and downloaded here
• Link includes a useful guide for chart review and how to assess relevant comorbidities

Preop Tips

• Don’t forget to include other pertinent studies, such as PFTs, TTE or stress echo results, Holter or Zio patch results, device interrogations, etc.
• Check the media tab and care everywhere for outside studies
• Review the Anesthesia tab in chart review to see prior anesthetics and airway/procedure notes
• Add the “Pre-Admission/Pre-op Orders” set at your institution to your favorites, if applicable
  • You can use this order set for day-of-surgery labs, rapid COVID-19 testing, pre-op IV placement if appropriate, ordering blood products to be available in blood bank, and you can order PO analgesics to be given in pre-op

Anesthetic Plan

• To start, consider referring to WikiAnesthesia's article for the case at hand.
  • If WikiAnethesia article not available, consider Jaffe’s Anesthesiologist’s Manual of Surgical Procedures, or talk with a senior resident
• Who is the surgeon? What is the expected procedure duration?
• Patient positioning
  • This may affect your line and monitor placement
  • May also have hemodynamic implications (e.g. steep Trendelenburg or reverse Trendelenburg)
• Is special monitoring required?
  • Is there an indication for an arterial or central line?
  • Is there an indication for an EEG monitor (Sedline, BIS)?
  • Is neuromonitoring part of the procedure plan?
• Blood products
  • Based on anticipated blood loss and patient’s pre-operative CBC, consider ordering blood products
• Induction
  • Choice of induction agent
  • RSI vs standard
  • Any relevant comorbidities that may change your induction plan (most commonly cardiac or pulmonary comorbidities)
• Have a well-thought out airway plan, as well as a backup plan • Maintenance • Inhalational agent vs TIVA
• Analgesia
  • Anticipate need for pressors, fluid resuscitation, frequent labs
• Emergence
  • Anticipate need for a more controlled emergence (e.g. high risk for bleeding into an enclosed space)
  • Consider the need for post-op intubation or monitoring in the ICU

Ordering extra equipment

• Consider whether your case will require additional equipment, such as a video laryngoscope, arterial line setup, special ETTs, etcetera and place the proper order for this equipment so it can be ready for your case in the morning

Device Management

• Patients with PPMs and AICDs present unique management challenges
• Important questions to ask about managing AICDs and pacemakers intra- operatively:
  • What is the site of surgery? If above the umbilicus, there is a risk of interference
  • Is the patient pacemaker dependent?
  • What type of device does the patient have, and what were the results of the last interrogation?
  • What effect will placing a magnet over the device have?
  • Does the patient’s device need to be interrogated or reprogrammed before or after surgery?
• When in doubt, best to contact the device rep
• As a backup, you can also page the device management service at your institution