Preoperative assessment

Yr 4 Anaesthesia Clerkship

Dr Patricia Chalmers
2010-2011

Objectives of preoperative assessment

Fasting status
The airway
Volume status
Systemic effects of anaesthetic agents
Allergies and genetic considerations
Risk Stratification
Respiratory and cardiovascular assessment
Patient sketches
Overview of history and examination

Preoperative Assessment
Objectives

To deliver good quality care

To establish doctor-patient rapport
To establish a clinical picture of the patient
To identify risk factors
To draw up a management plan
To optimise any concurrent medical conditions
To minimise the occurrence of critical incidents
in the perioperative period

Clinical Picture
Full medical history and physical examination
Points of specific relevance to anaesthesia:
RISK STRATIFICATION
General health of patient and functional
capacity
Surgical procedure
Concurrent medical conditions and medication
History of reactions and allergies to anesthesia
THE AIRWAY
Fasting Status Volume Status

FASTING STATUS

FASTING STATUS

6 hrs solids
4hrs liquids
(2hrs clear fluid /water)

The Full Stomach

Mechanisms

Reflux
Delayed gastric emptying
Raised abdominal pressure
Pharyngeal and laryngeal incompetence

The Full Stomach

Clinical conditions
GORD
Opioids
Autonomic neuropathy: diabetes
Pregnancy
Intestinal obstruction
Trauma
Head Injury
Myopathies/ bulbar palsy

Preoperative measures to
reduce risk of aspiration

Proton pump inhibitors

H2 blockers
Metoclopramide
0.3M Sodium citrate 30ml
Nasogastric tube where applicable

(Induction of anaesthesia: RSI)

THE AIRWAY

THE AIRWAY

Examination Facial swelling

Mouth opening
Dentition
Macroglossia
MALLAMPATI GRADE
Thyromental distance
Neck shape and mobility

Mallampati Grades

Mallampati Grades

Volume Status

VOLUME STATUS

Assess preoperative deficit

a.Clinical picture
b.Formula

Volume Status
TBW 70kg male
55-60% Body weight 45l
Intracellular 30 L
Extracellular 15 L
interstitial 12L
intravascular 3L

Clinical Dehydration
Body wt loss
5%

S&S
thirst, dry mouth

5-10%

reduced peripheral perfusion,

reduced skin turgor, oliguria,
postural hypotension, tachycardia
reduced CVP, lassitude,

10-15%

inc RR, hypotension, anuria,

delirium, coma

>15%

Life threatening

Formula
4mls/kg/hr for first 10 kg body weight
2mls/kg/hr for the next 20kg body wt
1ml/g /hr for every other kg body weight
Adult 2mls/kg/hr

Fluid replacement
Replace existing deficit: 50% deficit in 1st hr,
25% in 2nd hr,
25% in 3rd hr
Maintain fluid balance 2mls/kg/hr
Deficit: fasting/ burns/GI losses
Consider ongoing losses

Effects of anesthetic agents and drugs

Respiratory depression, impaired lung function , HYPOXIA
Depressed myocardial function HYPOTENSION
arrthymias,
Impaired delivery of O2 to the tissues

Effects of anaesthetic agents on

respiratory function
Depression of RC
Diminished muscle tone
Reduced lung compliance(loss of elastic
recoil) TLC TV FRC and Closing
volume
Atelectasis
Dead space(respiratory circuit)

Increased work of breathing

Increased ventilation /perfusion mismatch

Effects of anaesthetic agents

on cardiovascular function
Reduced contractility
Reduced stroke volume
Vasodilatation
Hypotension
Risk of reduced coronary perfusion
perfus

Effects of anesthetic agents and drugs

(contd)
Metabolism and elimination of drugs dependent
on hepatic and renal function
Muscle relaxation and paralysis
Stress Response
Adverse effect on co-morbidities

Perioperative Clinical Risks

Respiratory depression

Cardiac ischaemia
Arrthymias
Myocardial infarction
Stroke
Renal impairment

Risk Stratification

ASA grades
Surgical procedure
Age
BMI
Elective v Emergency

ASA GRADING
1. Healthy Patient
2.Mild systemic disease with no impact on
life
3.Systemic disease with limiting factors
4. Systemic disease with a constant threat
to life
5. Moribund patient

Grading of General Surgical

Procedures
1. Minor eg skin lesion
2. Intermediate eg inguinal hernia
arthroscopy
3. Major eg hysterectomy,
4. Major+ eg colonic resection, radical neck
dissection,

Preoperative assessment

Is there any evidence of active disease?

Are there any clinical risk factors?
What is the patients functional capacity?
What maintenance medication is the
patient on?
How can we optimise the patients clinical
condition?

Patient sketch 1
53 year old female for ligation of varicose veins
She has a history of asthma and neglects her
medication
o/e anxious
RR 24/min
widespread rhonchi
PEF 65%
Other systems unremarkable

Patient sketch 2
64 yr old male with intestinal obstruction for
a laparatomy
History of COPD previous heavy smoker
Gets breathless walking uphill or fast on
level ground
Coughing purulent sputum
FEV1 75%
On combined therapy with beta 2 agonist
and anticholinergic

Preoperative measures to improve

lung function

Stop smoking
Chest physio
Bronchodilators
Antibiotics
Steroids

Patient sketch 3

55yr old female for hysterectomy

Diabetic on twice daily insulin
BP 140/90
What investigations and management

Patient sketch 4
22 kg child for removal of plaster cast
Fasting from midnight
In theatre at 10.00am
What is her fluid deficit?

Patient Sketch 5
84 yr old female with a fractured neck of
femur
Tripped in bathroom lives alone and lay
there for 20 hours
She is thin stature, lives on tea, toast and
cake
History of CCF
On diuretics
? Considerations and management

Patient Sketch 6
40 yr old male for elective cholecystectomy
Heavy smoker
HR 80/min BP 200/115
Hb 14.0 gm/dl
Urea 8 mmols/l
Creatinine 140mmols/l

Patient sketch 7
40 yr old male for cholecystectomy
HR 80/min reg
BP 150/95
Hb 12.8 gm/dl
Urea 5.8 mmols/l
Creatinine 115 mols/l
Na 130mmols/l
K 4.5mmols/l

Patient sketch 8
44 year old female for mastectomy and
reconstruction
5 year history of angina, becoming more frequent
and increasing in severity over past 6 months
Both parents died from myocardial infarction
Coronary angiogram 2yrs ago no vessel disease
Ca antagonists,glyceryl trinitrate, isosorbide
dinitrate, verapamil,
Risk Factors Investigations Management

Perioperative Cardiac Risk in

relation to noncardiac surgery
Hi >5%: Vascular Aortic and peripheral
vascular surgery
Intermediate 1-5%: intraperitoneal,
intrathoracic, carotid endarterectomy, head
and neck , orthopaedic, prostrate,
Lo risk <1%: endoscopic, superficial,
cataract, breast, day stay procedures
ACC/AHA 2007 guidelines

Preoperative measures to improve

cardiovascular status

Continue maintenance meds

Control heart failure
Stabilise arrthymias
Stabilise uncontrolled hypertension
Lo dose short acting beta-blockers for IHD if Hi
or intermediate risk
Statins considered
Prophylactic antibiotics for valvular
disease/prosthesis

Systematic enquiry

RS
CVS
GIT HH GORD PUD
Renal system
Hepatic system
Endocrine diabetes thyroid
Bone joint and ct disorders RA
Haemotological anaemia coagulopathy DVT
Neurological and muscular epilepsy

Systematic Enquiry (contd)

Medications Diuretics, Steroids,
Diabetes, Epilepsy, Anticoagulants etc
Allergies
Social history Smoking, Alcohol
Previous Anaesthetic history PONV
FH genetic disorder SUX apnoea MH
Fasting status 6hrs (2hrs clear fluids)

Investigations
Age

ASA

Surgery

Spec cons

FBC

Elderly

2-5

2-4

Pallor
hge

U&Es

Elderly

3-5

3-4

Dehydration

3-4

Polytrauma

G&H/ Xmatch
ECG
CXR

M>40,
F>50

CVS 2 2
RS 3
CVS 2
RS 3

Pneumonia

INVESTIGATIONS
FBC
U&ES

Where indicated
Group & Hold/X-match
ECG
CXR
Glucose
Coag screen (spinal, epidural)
BGA
Cardiac ultrasound
RFTs

Key Points (1)

History: Full systemic history
Medications for maintenance
Allergies
Add previous anaesthetic history PONV
FH Sux apnoea, MALIGNANT HYPERTHERMIA
FASTING status
Anaesthetic Risk Stratification

Key Points (2)

Examination: Full systemic examination
Add THE AIRWAY
Consider Volume status G&H/X-match
Obtain Consent
Discuss pain management ---reassure
Continue maintenance meds
Draw up Anaesthetic Plan
Bear in mind effects of anaesthesia on patient and
effects of co-morbidities on the anaesthetic technique

Recommended Reading
Neville Robinson, George Hall
How to Survive in Anaesthesia
BMJ Books 2nd Ed 2002