Pre-Operative Evaluation and Preparation

Patient Identification and Medical Record Review

The American Society of Anesthesiologists recommends verifying patient identity, correct surgical procedure, correct surgical site, and obtaining informed consent 1
Review of previous medical records for history of airway difficulty with previous anesthetics, cardiovascular problems, and congenital or acquired medical conditions is recommended by the Anesthesiology society 2
The Anaesthesia journal suggests documenting current medications with careful review for inappropriate dosing, potential drug interactions, and medications requiring perioperative adjustment 3
Establishing whether a patient has a cardiac rhythm management device (pacemaker/ICD), defining device type, determining pacemaker dependency, and assessing device function is recommended by the Anesthesiology society 4

Focused History and Risk Assessment

The Anaesthesia journal recommends screening for obstructive sleep apnea (OSA) by asking about snoring, apneic episodes, frequent arousals during sleep, morning headaches, and daytime somnolence 2
Measuring baseline oxygen saturation and assessing for symptoms of sleep-disordered breathing is suggested by the Anaesthesia journal 5
Considering overnight saturation measurement or formal sleep study if severe OSA is suspected is recommended by the Anaesthesia journal 5
The Anaesthesia journal suggests obtaining a thorough allergy history including previous anaphylactic reactions, latex allergy, and drug allergies 6
High-risk groups for latex allergy include patients with atopy, children with spina bifida or multiple surgeries, healthcare workers, and those with fruit allergies (banana, chestnut, avocado) 7

Physical Examination

Evaluating the airway, nasopharyngeal characteristics, neck circumference, tonsil size, and tongue volume is recommended by the Anesthesiology society 2
Assessing for musculoskeletal abnormalities (osteoarthritis, kyphoscoliosis, fixed flexion deformities) is suggested by the Anaesthesia journal 3

Laboratory Testing

Obtaining a complete blood count (CBC) for patients with diseases increasing anemia risk, history of anemia, or when significant perioperative blood loss is anticipated is recommended by the Praxis Medical Insights 8
Pre-operative anaemia occurs in approximately 40% of hip fracture patients, according to the Anaesthesia journal 3
Considering pre-operative transfusion if Hb <9 g/dL, or Hb <10 g/dL with history of ischaemic heart disease is suggested by the Anaesthesia journal 3
Performing electrolyte and creatinine testing for patients with chronic disease and those taking medications predisposing to electrolyte abnormalities is recommended by the Praxis Medical Insights 8
Random glucose testing for patients at high risk of undiagnosed diabetes is suggested by the Praxis Medical Insights 8
Reserving coagulation testing (PT, aPTT, platelet count) for patients with history of bleeding, medical conditions predisposing to coagulopathy, or those taking anticoagulants is recommended by the Praxis Medical Insights 8

Medication Management

Reviewing the current medication list for inappropriate dosing, potential interactions, and perioperative continuation/discontinuation decisions is suggested by the Anaesthesia journal 3
Polypharmacy increases the likelihood of adverse drug reactions, with 20% of people aged >70 taking more than five medications, according to the Anaesthesia journal 3

Preoperative Fasting and Optimization

Allowing oral intake of clear fluids up to 2 hours and light meal up to 6 hours before induction is recommended by the World Journal of Emergency Surgery 1
Administering a complex carbohydrate drink (400 mL with 50 g CHO) 2 hours before surgery for elective patients is suggested by the World Journal of Emergency Surgery 1

Surgical Safety Checklist and Team Communication

Implementing the WHO surgical safety checklist with all 19 items and three pause points is recommended by the World Journal of Emergency Surgery 1
Conducting a pre-operative team brief to ensure appropriate equipment is available is suggested by the Anaesthesia journal 9
Alerting the surgical team, nursing, and anaesthetic support teams if latex allergy is diagnosed is recommended by the Anaesthesia journal 7

Antimicrobial and Thromboprophylaxis

Administering first-generation cephalosporin within 1 hour of incision is recommended by the World Journal of Emergency Surgery 1
Assessing all patients for postoperative nausea/vomiting (PONV) risk and providing 2-3 antiemetics for high-risk patients is suggested by the World Journal of Emergency Surgery 1
Using a combination of compression stockings and/or intermittent pneumatic compression with LMWH or unfractionated heparin for VTE prophylaxis is recommended by the World Journal of Emergency Surgery 1

Special Population Considerations

Patients with prior Fontan procedure, severe pulmonary arterial hypertension, cyanotic congenital heart disease, complex CHD with residua, or malignant arrhythmias should be managed at specialized centers unless it's an absolute emergency, according to the Circulation journal 10
Consultation with congenital heart disease experts is recommended for all CHD patients undergoing noncardiac surgery, according to the Circulation journal 10

Postoperative Planning

Planning postoperative care location based on pre-existing comorbidities, surgical procedure invasiveness, and need for parenteral opioids is recommended by the Anaesthesia journal 9
Establishing discharge plans preoperatively and providing patient/family education in oral, written, and/or pictorial format is suggested by the World Journal of Emergency Surgery 1

Documentation Requirements

Documenting sickle cell disease diagnosis clearly in the patient record so relevant teams are aware at all stages is recommended by the Anaesthesia journal 5
Recording cardiac rhythm management device information and perioperative management plan is suggested by the Anesthesiology society 4
Documenting allergy status, particularly latex and drug allergies, in multiple locations is recommended by the Anaesthesia journal 7

Guidelines for Pre‑operative Clearance in Pediatric Patients

Demographic and Growth Parameters

Calculate medication dosing and assess developmental appropriateness by recording age, weight (kg), and height for each child. 11
Document gestational age at birth because preterm infants may retain apnea of prematurity, influencing peri‑operative risk. 11

Medical History and Chronic Conditions

Identify chronic conditions such as congenital heart disease, arrhythmias, asthma or reactive airway disease, neurologic impairment, obesity, genetic syndromes (e.g., Down syndrome with cervical spine instability), and renal or hepatic dysfunction to guide anesthetic planning. 11
Screen for a history of snoring or obstructive sleep apnea; children with severe OSA require reduced opioid dosing and may have altered mu‑receptor sensitivity. 11
Record any seizure disorder and its current control status to anticipate intra‑operative seizure risk and medication interactions. 11
For females aged ≥12 years, assess pregnancy status; approximately 1 % of menarchal females presenting for surgery at pediatric hospitals are pregnant. [11][12]

Prior Surgical and Anesthesia Experience

Obtain a detailed history of previous surgeries or anesthesia exposures, focusing on any complications, unexpected responses, or adverse events, to anticipate recurrence. 11
Summarize prior relevant hospitalizations that may affect current peri‑operative management. 11

Allergy and Medication Review

Conduct a comprehensive drug‑allergy assessment, distinguishing true IgE‑mediated reactions from non‑allergic adverse effects, to avoid unnecessary alterations in anesthetic plans. 11
List all prescription medications with dose, timing, route, and administration site to detect potential drug‑drug interactions. 11
Document over‑the‑counter medications, as they may contribute to peri‑operative pharmacologic effects. 11
Inquire about herbal supplements (e.g., St John’s wort, ginkgo, ginger, ginseng, garlic, kava, valerian) because CYP450 inhibition can prolong sedation with agents such as midazolam. 11
Screen adolescents for illicit drug use, which may impact anesthesia safety and postoperative monitoring. 11

Recent Health Status and Immunization

Verify immunization status to assess infection risk during the peri‑operative period. 11
Ask about recent travel or exposure to sick contacts that could influence infection control measures. 11

Nutrition, Growth, and Development

Evaluate nutrition and growth concerns, including failure to thrive or feeding difficulties, to determine peri‑operative nutritional support needs. 11
Identify developmental delays or behavioral issues; consider mental‑health consultation before hospitalization to optimize cooperation and reduce anxiety. 13

Family History

Document family history of pseudocholinesterase deficiency or muscular dystrophy, which may affect anesthetic drug metabolism and muscle‑relaxant selection. 11

Special Equipment Needs

Note the use of home oxygen or CPAP, indicating significant cardiopulmonary disease that requires specialized peri‑operative monitoring and ventilation strategies. 11

Determine the individual(s) with parental responsibility to ensure proper consent procedures are followed for the child’s surgery. 12

Pre‑Anaesthetic Evaluation: Evidence‑Based Recommendations (American Society of Anesthesiologists)

Core Components of the Assessment

Medical Record Review

The ASA recommends that the pre‑anaesthetic record review document current diagnoses, with particular focus on cardiovascular, pulmonary, and renal diseases, to inform peri‑operative risk stratification. 14, 15

Focused Physical Examination

The ASA requires a focused examination of the airway, lungs, and heart together with vital signs; airway assessment (including Mallampati classification) achieved 100 % expert consensus. 16, 17, 18
Pulmonary examination (auscultation of both lung fields, respiratory rate, use of accessory muscles) reached 88 % consensus among experts. 14, 18
Cardiovascular examination (heart rate, rhythm, blood pressure, murmurs, gallops) reached 81 % consensus. 14, 18

Timing Relative to Surgical Invasiveness

High surgical invasiveness – The ASA advises that the complete pre‑anaesthetic evaluation (record review, interview, physical exam) be performed prior to the day of surgery (89 % consultant consensus, 75 % ASA member consensus). 14, 19, 15
Medium surgical invasiveness – Evaluation may occur on or before the day of surgery; 58 % of consultants prefer prior assessment, with an overall 61 % ASA member consensus. 14, 19
Low surgical invasiveness – Evaluation on the day of surgery is acceptable (59‑69 % consensus). 14, 19
High‑severity disease – Patients with high disease severity must be evaluated before the surgery day regardless of invasiveness. 19, 16

Selective Pre‑operative Testing

The ASA states that routine pre‑operative laboratory tests do not meaningfully affect peri‑operative management and should be ordered only when a specific clinical indication exists. 20, 17

Complete Blood Count (CBC)

CBC is indicated when there is a history of anemia or bleeding disorders or when significant intra‑operative blood loss is anticipated. 17, 20

Electrocardiogram (ECG)

ECG is recommended for men > 60 yr, women > 65 yr, patients with known cardiovascular disease, diabetes, or cardiac symptoms; it is not indicated for asymptomatic young patients undergoing low‑risk surgery. 21, 18

Electrolytes & Creatinine

Serum electrolytes and creatinine should be obtained in patients with chronic kidney disease, medications affecting electrolytes, diabetes, or liver disease. 17

Coagulation Studies (PT/INR, aPTT, Platelets)

Coagulation testing is indicated for bleeding disorders, liver or renal dysfunction, and current anticoagulant therapy; evidence is insufficient to support routine testing before regional anaesthesia. 17, 20

Documentation Requirements

The ASA mandates recording the ASA Physical Status Classification as part of the pre‑anaesthetic documentation. 15

Common Pitfalls to Avoid

Ordering routine tests without clinical indication wastes resources and does not improve outcomes. 20, 17
Inadequate airway assessment is the most preventable cause of anaesthetic morbidity. 14, 18
Late‑stage assessment of high‑risk patients prevents adequate optimisation; evaluation should occur well before the surgery day. 14