Preoperative Assessment for Outpatients

Goals & Scope - Outpatient Checkup Kickoff

• Primary Goals:
  • Identify & mitigate patient-specific surgical risks.
  • Optimize existing medical conditions.
  • Formulate safe, individualized anesthetic plan.
  • Educate patient, allay anxiety, obtain informed consent.
  • Reduce perioperative morbidity & unplanned admissions.
  • Minimize same-day cancellations & delays.
  • Ensure timely, safe post-anesthesia discharge.
• Scope:
  • Targeted history (medical, surgical, anesthetic).
  • Focused physical exam, including airway assessment (e.g., Mallampati).
  • ASA physical status classification.
  • Review relevant investigations.
  • Medication management.
  • Clear fasting instructions (NPO).

⭐ ASA physical status is a key independent predictor of perioperative complications.

History & Exam - Sleuthing for Safety

• Key History:
  • Co-morbidities: Cardiac (MI, Angina, HF), Resp (Asthma, OSA), DM, HTN.
  • Anesthetic Hx: Complications? Malignant Hyperthermia (MH) family Hx?
  • Medications: Key: Anticoagulants, antiplatelets, insulin, oral hypoglycemics.
  • Allergies: Drugs (e.g. penicillin), latex.
  • Fasting: Standard NPO (2h clear fluids, 6h light meal).
  • Habits: Smoking (stop >4wks), ETOH, drugs. Functional Capacity (>4 METs).
• Focused Examination:
  • Vitals: BP (e.g. SBP <160, DBP <100), HR, SpO2.
  • Airway: 📌 LEMON assessment (Look, Evaluate 3-3-2, Mallampati, Obstruction, Neck mobility).
    • Mallampati Score (Class I-IV).
    • Thyromental Distance (>6.5cm).
    • Mouth Opening (>3cm).
  • Systemic: Focused cardiac & respiratory exam.

⭐ Recent MI (<1 month) or unstable angina are significant red flags for ambulatory surgery.

Labs & ASA Class - Tests & Risk Tally

• Labs: Selective, not routine for ASA I/II. Based on H&P, comorbidities, procedure.
  • Hb: Anemia, blood loss.
  • K+: Diuretics, renal issues.
  • Glucose: Diabetes.
  • ECG: Age >50 (or >40 + risks), cardiac/systemic disease.
  • hCG: Women of childbearing age.
• ASA Class:
  • I: Healthy. II: Mild systemic disease.
  • III: Severe systemic disease (limits activity).
  • IV: Severe, life-threatening. V: Moribund. VI: Organ donor. 'E': Emergency.
• Risk Tally: ASA + surgery complexity + comorbidities → outpatient suitability.

⭐ ASA class strongly predicts perioperative risk but doesn't solely dictate ambulatory surgery appropriateness.

Fasting & Meds - NPO & Meds Protocol

• NPO (ASA Guidelines):
  • Clear liquids: 2h (water, clear tea/coffee, no pulp juice)
  • Breast milk: 4h
  • Formula, non-human milk, light meal: 6h
  • Fried/fatty foods, meat: 8h
• Medication Management:
  • Continue essential meds (β-blockers, statins).
  • ACEi/ARBs: Often held surgery day (check policy).
  • Oral hypoglycemics: Hold morning dose.
  • Insulin: Adjust (e.g., 1/2 long-acting dose).
  • Anticoagulants/Antiplatelets: Individualized plan.
  • Herbals: Stop 1-2 wks pre-op.
  • MAOIs: Stop 2 wks pre-op.

⭐ Routine morning cardiac, antihypertensive (except ACEi/ARBs per some), and respiratory medications should be taken with a sip of water up to 1-2 hours before surgery.

Special Cases & Discharge - Cases & Clear-to-Go

• Special populations (OSA: STOP-BANG, MH risk, elderly: comorbidities, peds: age-specific) need careful assessment.
• Discharge: PADSS score ≥9 or modified Aldrete ≥9.
• Criteria: Stable vitals, pain/PONV controlled, ambulation (age-appropriate), voiding, responsible escort, clear instructions.

⭐ For patients with OSA, ensure they are back to baseline respiratory status and have appropriate home care/monitoring plans.

High‑Yield Points - ⚡ Biggest Takeaways

• ASA I & II ideal for outpatient surgery; selected ASA III with stable disease.
• Airway assessment (Mallampati, TMD) is crucial to anticipate difficult intubation.
• Adherence to NPO guidelines (2h clear liquids, 6h light meal) is critical.
• Manage medications: continue essentials; hold specific agents like oral hypoglycemics, anticoagulants.
• Screen for OSA (STOP-BANG) and assess risk for postoperative complications.
• Confirm responsible adult escort and safe post-discharge environment.
• Review previous anesthetic records for complications or allergies.