Why is a Pre-Operative Assessment Important?

Pre-operative assessments are important before any type of surgical procedure.

Introduction

   You have decided it is time to consider surgery to find relief to your problems. Before going under the knife your surgeon may want to ensure if you are healthy enough to go through with the procedure. Most operations often require some form of general anesthesia and your body goes under stress. This stress may affect the function of vital organs that if not in top shape, may not withstand the whole procedure. To ensure the safety of patients, especially with elective operations, surgeons will often require patients to have some preliminary tests done to have an idea on how some vital organs are functioning depending on their current state of health. This is referred to as as pre-operative assessment. The main goal of this assessment is to identify patient co-morbidities that have the potential to become complications during the peri-operative and post-operative setting. Not all patients require pre-operative assessments. Ultimately, a pre-operative assessment will allow physicians to assess and reduce possible risks that may occur during surgery.

Who requires a pre-operative assessment?

  The American Society of Anesthesiologist (ASA) has developed a Physical Status Classification System (ASAPS) where patients are categorized according to their physiological status that can be helpful in predicting operative risk. The ASAPS is categorized as followed:

   Patients with an ASAPS classification of ASA 1 or ASA 2 – generally don’t require a pre-operative evaluation, but it is subject to discretion of the surgeon or primary care physician. For patients with ASAPS classification of ASA 3 and above, the surgeon will refer these patients for a pre-op medical consultation with their PCP.

The Pre-Operative Assessment 

  The pre-operative assessment entails three categories: pre-op history, pre-op examination, and pre-op testing. Usually, a patient undergoing an elective surgery will be scheduled for a pre-operative assessment 2-4 weeks prior to the day of surgery. Also, during this period of pre-op evaluation some patients may require evaluations from more than one physician depending on the different chronic conditions they may have. Besides visiting your PCP for surgical clearance, some patients may need to visit a heart doctor, a lung doctor, among others for a full and focused evaluation.

Pre-Op History

History of Presenting Complaint: a brief history of why the patient has presented to clinic and what procedure the patient has been scheduled for.

Past Medical History: a patient's past medical history is focused and important for specific reasons: 

Past Surgical History: knowledge of prior surgeries, response to anesthetics in the past, if there were adverse responses – were they peri-operative or post-op – are very important to know.

Drug History: full drug history is required to identify medications that require stopping or alteration before the procedure. Also, it is important to know about drug allergies or adverse responses.

Family History: any adverse reactions in surgery of immediate family should be documented, since there are genetic traits that pre-dispose patients to have adverse response to anesthetics such as malignant hyperthermia, a life-threatening condition.

Social history: smoking history and alcohol intake, may clue in how a patient may respond during the post-op period and how well will they heal afterwards. For example, smokers are recommended to discontinue smoking 8 weeks prior to surgery since it's been shown to delay the healing process.

Pre-Op Examination

In the pre-op examination, two types of examinations are performed:

Pre-Op Testing

  Pre-operative testing depends on multiple factors such as age, co-morbidities, and type of procedure. Minor surgery (i.e. draining an abscess) rarely need further testing. Intermediate surgery (i.e. knee arthroscopy) may only require some testing, especially in those patients with kidney and/or heart problems. Major surgery (i.e. total joint replacement) requires at least some testing even with normal healthy patients (ASA 1). The National Institute for Health and Care Excellence (NICE) guidelines provide recommendations for specific surgery and ASA grades.

(Link: https://www.nice.org.uk/guidance/ng45/resources/colour-poster-2423836189)

Below are mentioned tests and imaging that can be done prior to a surgical procedure.

Conclusion

   Pre-operative assessments, besides providing safety to patients undergoing surgery, are an excellent opportunity for patients to gather more information about their state of health and to obtain recommendations to improve their quality of life. Although the surgeon and evaluating physicians work together to determine if a patient is fit for surgery, after everything is assessed and possible risks are outlined and discussed, the final decision to proceed with surgery belongs to the surgeon and the patient.

Author
Ernesto P. Quinones Gonzalez Third year Medical Student at University of Medicine and Health Sciences (UMHS)

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