Pre-op evaluation
What to look for the night before, how to classify it, and how to present it to your resident in 60 seconds.
ASA physical status
ASA Physical Status Classification System (last amended Dec 13, 2020). Describes baseline health — not the total surgical risk.
| Class | Definition | Adult examples (ASA) |
|---|---|---|
| I | Normal healthy patient | Healthy, non-smoking, no or minimal alcohol |
| II | Mild systemic disease | Current smoker, social alcohol, pregnancy, obesity (30 < BMI < 40), well-controlled DM/HTN, mild lung disease |
| III | Severe systemic disease | Poorly controlled DM/HTN, COPD, BMI ≥ 40, active hepatitis, alcohol dependence, pacemaker, moderately reduced EF, ESRD on dialysis, MI/CVA/TIA/coronary stent > 3 months ago |
| IV | Severe systemic disease that is a constant threat to life | MI/CVA/TIA/coronary stent < 3 months ago, ongoing ischemia, severe valve dysfunction, severely reduced EF, shock, sepsis, DIC, ESRD not on dialysis |
| V | Moribund; not expected to survive without the operation | Ruptured AAA, massive trauma, intracranial bleed with mass effect |
| VI | Brain-dead organ donor | — |
| E | Emergency modifier | Delay would increase threat to life or body part |
Official ASA examples (adult, pediatric, obstetric) →
Fasting
ASA guidance for healthy patients having elective procedures (2017, with the 2023 modular update). These are minimums — not a “green light.” LA General policy and the attending decide.
| Intake | Minimum fast |
|---|---|
| Clear liquids (water, pulp-free juice, black coffee/tea; carbohydrate drinks in adults) | 2 h |
| Breast milk | 4 h |
| Infant formula, non-human milk | 6 h |
| Light meal | 6 h |
| Fried or fatty food, meat | 8 h or more |
Risk tools
RCRI (cardiac)
Six factors: high-risk surgery · ischemic heart disease · heart failure · cerebrovascular disease · insulin-treated diabetes · creatinine > 2 mg/dL. Use with the 2024 ACC/AHA perioperative guideline. Calculator →
Functional capacity
≥ 4 METs ≈ climbing two flights of stairs without stopping. Poor or unknown capacity changes the cardiac workup conversation.
STOP-Bang (OSA)
Snoring · Tired · Observed apnea · Pressure (HTN) · BMI > 35 · Age > 50 · Neck > 40 cm · male Gender. ≥ 3 intermediate, ≥ 5 high risk. stopbang.ca →
PONV (Apfel)
Female · non-smoker · PONV/motion sickness history · post-op opioids. Calculator →
Airway
Mallampati, mouth opening, thyromental distance, neck mobility, dentition, prior airway records. Full airway assessment →
Present it in 60 seconds
“This is a [age]-year-old having [procedure] for [indication]. The main anesthesia issues are [top 3]. Prior anesthesia/airway history shows [key facts]; I still need to confirm [missing info]. I’d propose [technique, airway plan, monitoring/access, key concerns, post-op plan] for discussion. My questions are [1–3].”
Practice with a fictional case → · Real patient details stay in the approved EHR — never in texts or this site.