Dr S Stott,
Aberdeen Royal Hospitals NHS Trust, Aberdeen, Scotland, UK.

Introduction		Past medical history
History & examination		Airway assessment
Respiratory system		Further investigations
Cardiovascular system		Summary

The preoperative preparation and assessment is a vital part of the anaesthetic care given to patients scheduled for both routine and emergency surgery. All patients should be seen and assessed by the anaesthetist who is responsible for the administration of their anaesthetic. This practice not only avoids the chance of mistakes during "hand overs" but ensures continuity and rapport for both the anaesthetist and the patient.

The clinical assessment is best conducted using the standard format of history, examination and then further investigations. The latter will, in the majority of cases, serve to confirm the impression gained from an accurate history and examination, and should not be used to replace a thorough clinical assessment.

 
History and examination

The history should concentrate on the symptoms that alert the anaesthetist to potential problems during anaesthesia as well as those involving the general condition of the patient. In the majority of cases these will relate to the respiratory and cardiovascular systems.

 
Respiratory system

Symptoms of respiratory disease that should be sought are cough, shortness of breath and haemoptysis (blood in the sputum). The production of purulent sputum and the presence of wheeze may also indicate underlying lung disease. The functional ability of the patient can be assessed by questions such as "how far can you walk before you get short of breath? " or "what activities make you short of breath? ". Valuable information may be revealed about a patient's cardio-respiratory reserve.

The presence of a productive cough is associated with an increase in postoperative chest complications and if it is of recent onset then consideration should be given to postponement of surgery and the commencement of appropriate treatment with antibiotics and chest physiotherapy. If the patient has a chronic productive cough then elective surgery should be postponed only if the patient has additional signs suggesting an infection. On examination of the chest the presence of altered breath sounds may indicate underlying lung disease. Bronchospasm and increased airway sensitivity are detected by the presence of expiratory rhonchi (wheeze). Fine inspiratory crepitations which do not clear after one or two deep breaths are caused by pulmonary congestion from left ventricular failure; while coarse crepitations indicate excess bronchial secretions. The presence of pleural effusions are indicated by a dull percussion note and reduced or absent breath sounds.

 
Cardiovascular system

When assessing the cardiovascular system it must be remembered that patients can have heart disease without symptoms or signs. In the developing world valvular heart disease is more common than ischaemic diease and a history of rheumatic fever must always be sought. Mitral stenosis occurs in 60% of patients who have had rheumatic fever but 30% of patients with mitral stenosis give no history of rheumatic fever. Symptoms of valvular heart disease include breathlessness on exertion, paroxysmal nocturnal dyspnoea, palpitations, haemoptysis and dizziness, fainting and angina. With a thorough history and clinical examination the cardiovascular reserve and the degree of stenosis, regurgitation and mobility of the valves can be estimated. The most accurate method of diagnosing the cause of a cardiac murmur is Echocardiography (an ultrasound examination of the heart) if this is available. In general all diastolic murmurs and loud systolic murmurs which are accompanied by a thrill are abnormal and indicate underlying structural heart disease. When the cardiac function is seriously compromised then symptoms and signs of cardiac failure will become apparant.

Signs of left ventricular failure include tachycardia, gallop rhythm, fine basal inspiratory crepitations, evidence of an enlarged heart and displaced apex beat. Right heart failure produces a raised jugular venous pressure wave, hepatic enlargement and peripheral oedema.

Ischaemic heart disease may be silent but is indicated by a history of angina or myocardial infarction. Precipitating factors such as anaemia or valvular heart disease should be sought. Angina associated with breathlessness is indicative of left ventricular dysfunction and a recent history of myocardial infarction (heart attack or coronary thrombosis) is of particular importance, as it increases the risk of perioperative myocardial infarction (MI). See Table 1 below:

Time since MI	Incidence of perioperative MI
< 3 months	36%
3-6 months	16%
> 6 months	6%

The degree of risk of cardiovascular disease can be assessed by using the Goldman Index (Table 2).

Risk factor	Score
Third heart sound / gallop rhythm	11
MI within 6 months	10
>5 Ventricular ectopics per min	7
Rhythm other than sinus	7
Age > 70 years	5
Emergency surgery	5
Aortic stenosis	3
Abdominal or thoracic operation	3
Poor general condition	3

A total over 13 gives a poor prognosis (11% life threatening complications) and above 26 has a mortality of 50% and only life- saving operations should be considered. Note that it is almost entirely based upon clinical findings.

(Continued...)

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