Preoperative evaluation3

Preoperative Evaluation
Height________Weight___________kg Age_________
Date/Time_______________
Planned Procedure__________________________________________________ Extraordinary Circumstances?________________ Airway Evaluation
ASA Classification:______
NPO Status: > 6 hours RSI? Y/N
Hx of Difficult Intubation
Atlanto-occipital extension <30° >35° Trache Stoma/Hoarse Voice/Stridor/Head or Neck Pathology Mallampati Classification I II III IV
Pre-operative vital signs

Antibiotic Prophylaxis
BP_______ P_______ Resp_______ SaO2______ Temp_______ Medical Hx
Current Medications
Previous Surgeries

Problems with Anesthesia
Family Hx
Cardiovascular disease:
Pulmonary Disease:
Endocrine Disorders:
Liver Disease:
Renal Disease:
Neurological Disorders:
Gastrointestinal Disorders:
Fluid Plan: ~
NPO Deficit: ~
EBV ♂70ml/kg, ♀65ml/kg, PMI 100ml/kg, TNB 90ml/kg 4. For patients more than 20kg: patient weight in kg + 40 = ml/hr ABL=EBV x (HCT-30)/HCT or Hgb Or 20% of EBV ~ Premedications
The goals of premedication include: anxiety relief, sedation, analgesia, amnesia, an-
tisialagogue, ↑ gastric pH, ↓ gastric volume, attenuate SNS reflex, ↓ anesthesia re- quirements, prevent bronchospasm, prophylaxis against allergic reactions, ↓ post-op midazolam______mg fentanyl______mcg ABx_____________gm
CREATED BY Ryan White, SRNA Class of 2007 Sedatives/Hypnotics
Induction dose of Propofol__________(1.5-2.5mg/kg)4-8 min Maintenance dose of Propofol ____________(25-200µg/kg/min)
Induction dose of Etomidate_________(0.15-0.3mg/kg) 5 min Maintenance dose of Etomidate___________(25-100µg/kg/min)
Induction dose of Thiopental________(3.0-5.0mg/kg) 4 min Maintenance dose of Thiopental___________(0.5-1.5mg/kg)
Induction dose of Ketamine_________(0.5-2.5mg/kg) 10 min Maintenance dose of Ketamine____________(75-150µg/kg)
Induction dose of Methohexital______(1-2mg/kg) <4 min
Maintenance does of Methohexital_________(50-100µg/kg/min) Induction dose of Succinylcholine_________(0.5-1.0mg/kg) Bolus_____________(0.075-0.15mg/kg) Induction dose of Mivacurium____________(0.15-0.25mg/kg)Bolus_____________(0.075-0.15mg/kg) 20-30 Glycopyrrolate Induction dose of Cisatracurium_________(0.15-0.25mg/kg) Bolus_____________(0.03mg/kg) 25-44 min Induction dose of Rocuronium___________(0.5-1.0mg/kg) Bolus_____________(0.1-0.3mg/kg 45-90 min Induction dose of Vecuronium___________(0.08-0.1mg/kg) Bolus_____________(0.02mg/kg) Induction dose of Pancuronium__________(0.06-0.12mg/kg) Bolus_____________(0.01mg/kg) 40-80 min Induction dose of Atracurium____________(0.3-0.5mg/kg) Bolus_____________(0.08-0.1mg/kg) 35-50min kg (60s/5-20m) Inhalation Agents
Usual Range / (1
Blood/Gas
Blood/Fat
Blood/Brain/
Metabolite%
MAC) / MAC95
Halothane
Isoflurane
Desflurane
Sevoflurane
Bolus Dose
Induction Dose
Maintenance
T½ (hours)
Vd (L/kg)
Sufentanil
Fentanyl
Remifentanil
Alfentanil
Hydromorphone
Morphine
Meperidine
Sympathomimetics
Dose Onset
Duration
Elimination
Beta Antago-
Dose Onset
Selectivity
Propranolol 0.5-3mg <2min <10min NSβ1β2 Antag Vasopressin is contraindicated in renal disease, seizure disorders, CAD, and HTN Vasodilators
Dose Onset
Duration
Elimination
Post-Op visits/Learned

Source: http://www2.smumn.edu/deptpages/~nap/PreoperativeAssessmentSheet.pdf