Preoprative evaluation

Dept of anesthesia and critical care ,UB

Preoprative evaluation is defined as a

process of clinical assessment that
precedes the delivery of anesthesia
care for surgery and for non surgical
procedures.

Goals of preoperative assessment

1. Assessment of the patients overall health status.
2. Uncovering of hidden conditions that could cause problems
both during and after surgery.
3. Perioperative risk determination.
4. Optimization of the patients medical condition in order to
reduce the patients surgical and anesthetic perioperative
morbidity or mortality.
5. Development of an appropriate perioperative care plan.
6. Education of the patient about surgery, anesthesia,
intraoperative care and postoperative pain treatments in
the hope of reducing anxiety and facilitating recovery.
7. Reduction of costs, shortening of hospital stay, reduction of
cancellations and increase of patient satisfaction.
8. Informed consent

Goals of the preoperative

evaluation is to ensure that the
patient is in the best (or optimal)
condition.

Information sources: preoperative evaluation consists of

consideration
of informations from multiple sources
that may
include:
Patient medical records
Interview
Physical examination
Investigations

Steps of the preoperative

evaluation :
I.Problem Identification
II. Risk Assessment
III. Preoperative Preparation
IV. Plan of Anesthetic Technique

I. Problem Identification
through :History

(including a review of the patient's chart)

Physical examination
investigation

History
The history is the most important component of the
preoperative evaluation. The history should include :
a past and current medical history
a surgical history: significant blood loss
a family history: adverse reactions associated with
anesthesia should also be obtained
a social history :use of tobacco, alcohol and illegal drugs,
a history of allergies, current and recent drug therapy,
unusual reactions or responses to drugs
any problems or complications associated with previous
anesthetics

Previous anaesthetics
PONV
allergy
malignant hyperpyrexia
difficult airway
difficult IV access

 The history should include a complete review of systems to look for

undiagnosed disease or inadequately controlled chronic disease.
Diseases of the cardiovascular and respiratory systems are the most
relevant in respect of fitness for anesthesia and surgery:

Cardiovascular : hypertension ; ischemic , valvular or congenital heart disease; CHF

or cardiomyopathy, , arrhythmias

Respiratory : COPD; restrictive lung disease; altered control of breathing

(obstructive sleep apnea, CNS disorders, etc.)

Neuromuscular : CVA's; seizures; spinal cord Injury; disorders of NM junction e.g

myasthenia gravis, MH

Endocrlne : DM; thyroid disease; pheochromocytoma; steroid therapy

GI - Hepatic : hepatic disease; gastresophageal reflux

Renal : renal failure

Hematologic : anemias; coagulopathies

 Physical Examination:Should focus on evaluation of :

Upper airway
Respiratory system
Cardiovascular system
other systems problems identified from the history

airway evaluation should include:

-Head and neck examination
-Face
-Oral cavity :

mouth opening

mandibular space
tongue
teeth
Mallampati classification

Abnormal

Small or recessed chin: micrognatia,

macroglossia
- Buck, protruded, & loose teeth
Inability to open mouth normally
High arched palate
Tonsillar hypertrophy
Neck has limited range of motion
Low set ears
Significant obesity of the face/neck
-swellings around the head and neck

Mallampati test:
-Pridctive test for difficult laryngoscopy
-used alone it correctly predicts about 50% of difficult laryngoscopies and
has
a false positive rate of up to 90%.
-Examine the patients oropharynx from opposite the patients face while
the patient opens their mouth maximally and protrudes their tongue
without phonating. Check for visibility of or pharyngeal structures :
Class I :Faucial pillars, soft palate ,and uvula visible
Class II:Faucial pillars , and soft palate visible uvula tip masked by the
base of
the tongue.
Class III:Soft palate is visible
Class IV:Soft palate is not visible
class III & IV are associated with an increased risk of difficult
laryngoscopy.

Mallampati scoring system

Other pridictive tests: Thyromental distance (Patil test ):distance from the tip of thyroid
cartillage
to the tip of mandible, neck fully
extended.
Normal >7cm. < 6 cm predicts approx. 75% difficult laryngoscopies
Sternomental distance(Savva test):The distance from the upper
boarder
of manubrium to the tip of the mandible ,neck fully extended and
mouth
closed.
< 12.5 cm associated with difficulty ( positive pridictive value 82 %)
Mandibular protrusion:
inability to protrude lower incisors beyond the upper incisors
associated with increased risk of difficult laryngoscopies.

INVESTIGATION
INVESTIGATION

Lab tests : should be ordered based on information obtained from the history
and physical exam, the age of the patient and the complexity of the surgical
procedure. Routine laboratory tests in patients who are apparently healthy
on clinical examination and history are not beneficial or cost effective.
only if indicated from the preoperative history and physical examination.
"Routine or standing" pre operative tests should be discouraged
-FBC : anticipated significant blood loss, suspected hematological disorder (eg.anemia,) or recent
chemotherapy.
-Electrolytes : diuretics, chemotherapy, renal or adrenal disorders
-ECG : age >50 yrs. ,history of cardiac disease, hypertension, peripheral vascular disease, DM,
renal, thyroid or metabolic disease.
-Chest X-rays: prior cardiothoracic procedures ,COPD, asthma, a change in respiratory symptoms
in the past six months.
-Urine analysis : DM, renal disease or recent UTI.
tests for different systems according to history and examination

Risk Assessment
-Perioperative risk is a function of : the preoperative medical condition of the patient,
the invasiveness of the surgical procedure and
the type of anesthetic administered.
-Most of the work, however, addresses the operative risk according to the patient's
preoperative medical status.
American Society of Anesthesiologists Classification of Physical Status(The ASA
grading system):-simple description of the physical state of a patient (Table 2).
- one of the few prospective descriptions of the patient general health which
correlates
with the risk of anesthesia and surgery1516. It is extremely useful and should applied
to all patients who present for surgery.
-Increasing physical status is associated with increasing mortality.
-Emergency surgery increases risk dramatically, especially in patients in ASA class 4
and 5.

ASA Physical Status Classification System

medical status

mortality

ASA II
ASA

normal healthy patient without organic,

biochemical, or psychiatric disease

ASA
ASA IIII

mild systemic disease with no significant

impact on daily activity e.g. mild diabetes,
controlled hypertension, obesity .

Unlikely to have
an impact
0.27-0.4%

ASA
ASA III
III

severe systemic disease that limits activity e.g.

angina, COPD, prior myocardial infarction

Probable impact
1.8-4.3%

ASA
IV

an incapacitating disease that is a constant

threat to life e.g. CHF, unstable angina, renal
failure ,acute MI, respiratory failure requiring
mechanical ventilation

Major impact
7.8-23%

ASA V
ASA V

moribund patient not expected to survive 24

hours e.g. ruptured aneurysm

9.4-51%

ASA
VI

brain-dead patient whose organs are being

harvested

ASA IV

0.06-0.08%

ASA VI

For emergent operations, you have to add the letter E after the
classification.

III. Preoperative Preparation

1.Anesthetic indications:
Preanesthetic medication:
is the use of drugs prior to anesthesia to make it more safe and pleasant.

-To relieve anxiety benzodiazepines.

-To prevent nausea and vomiting antiemetic.
-To provide analgesia opioids.
-To prevent bradycardia and secretion atropine.
-Prophylaxis for pulmonary aspiration -H2-Antagonist , Non-particulate
antacids

2.Surgical indications:
-Antibiotic prophylaxis for infective endocarditis.
-Prophylaxis against DVT for high risk patients : low-dose heparin or aspirin
intermittent calf compression, or warfarin.

3.Co-existing Disease indications:

-Some medications should be continued on the day of surgery e,g B blockers,
thyroxine. Others are stopped e.g oral hypoglycemics
- Steroids within the last six months may require supplemental steroids

Common Preoperative Medications, Doses,

and Administration Routes (adult)
MEDICATION

ADMINISTRATION
ROUTE

DOSE (mg)

Lorazepam

Oral, IV

0.54

Midazolam

IV

Titration of 1.02.5-mg doses

Fentanyl

IV

Titration of 25100g doses

Morphine

IV

Titration of 1.02.5-mg doses

Meperidine

IV

Titration of 1025-mg doses

Cimetidine

Oral, IV

150300

Ranitidine

Oral

50200

Metoclopramide

IV

510

Atropine

IV

0.30.4

Glycopyrrolate

IV

0.10.2

Scopolamine

IV

0.10.4

Summary of Fasting Recommendations to

Reduce the Risk of Pulmonary Aspiration
Ingested Material
Period

Minimum Fasting

Clear liquids

(Hours)
2

Breast milk
Infant formula
Non-human milk
Light meal

4
6
6
6

IV. Plan of Anesthetic Technique

1. Is the patient's condition optimal?
2.Are there any problems which require consultation
or special
tests?
3.Is there an alternative procedure which may be
more
appropriate?
4. What are the plans for postoperative
management of the
patient?
5. What premedication if any is appropriate?

 Finally, we plan our anesthetic

technique :
1. Local or Regional anesthesia with 'standby
monitoring with or without sedation.
2. General anesthesia; with or without intubation.
Spontaneous or controlled ventilation is used.
3. Combined regional with general anesthesia.