PREOPERATIVE

EVALUATION
Lennon D. Ponta-oy
Clinical Clerk

October 6, 2018
The American Society of Anesthesiologists (ASA) has
published a practice advisory that suggests a preanesthesia
visit should include the following:

 An interview with the patient or guardian to establish a medical,

anesthesia and medication history
 An appropriate physical examination
 Indicated diagnostic testing
 Review of diagnostic data (laboratory, electrocardiogram, radiographs,
consultations)
 Assignment of an ASA physical status score (ASA-PS)
 A formulation and discussion of anesthesia plans with the patient or a
responsible
Preoperative Evaluation

 MANDATORY
 Is the initial step in the preparation of a patient for the
operating room.

 Consists of:
1. Review of previous medical records
2. Survey of past and present medical & surgical problems
3. Well-directed physical examination
Goals of Pre-operative Evaluation

1. Reduce patient risk and the morbidity of surgery

2. Promote efficiency and reduce costs
3. Increasing resource utilization

PRIMARY GOAL: Minimize morbidity and mortality

Objectives of a Pre-operative Evaluation
1. To review database
2. To perform physical exam
3. To establish a doctor-patient relationship
4. To obtain consent
5. To make an anesthesia plan
6. To reduce morbidity and mortality perioperatively
Preoperative Evaluation Form

 basis for formulating the best anesthetic plan tailored to the

patient.
 should aid the anesthesiologist in identifying potential
complications, as well as serve as a medico-legal document.
 information obtained must be complete, concise, and
legible.
 I. PREOPERATIVE EVALUATION

A. History
B. Preoperative Physical Examination
C. Indicated diagnostic testing
D. Overall Assessment of Perioperative Risk
E. American Society of Anesthesiologists
Classification
Areas of Concern & Rule of Threes
 Three aspects of acute history
1. History of present illness
2. Exercise tolerance
3. Patient’s visits to his physician

 Three aspects of chronic history

1. Medications
2. Social history
3. Past medical & family history

 Three aspects of physical examination

1. Airway
2. Cardiovascular
3. Pulmonary
Medical History
 HPI
 Past Medical History
Medications
Allergies
Previous Surgical and Anesthetic History
- difficult airway, a history of malignant hyperthermia,
and the individual's response to surgical stress and specific
anesthetics.
 Family History
Medications
Medication Anesthetic Implication

Aspirin Platelet dysfunction & bleeding

potential

Aminoglycosides Can potentiate nondepolarizing

relaxants

Insulin Hypoglycemia if not monitored

Lithium Potentiate neuromuscular blockers

Monoamine Oxidase Inhibitors Increased catecholamine stores

Warfarin Excessive intraoperative bleeding

Pulmonary
 Tobacco use
 Shortness of breath, cough, wheezing, stridor, and
snoring or sleep apnea
- Asthma
- Obstructive Sleep Apnea (OSA)
 URTI (presence and recent history)
Cardiovascular
 Uncontrolled hypertension
 Unstable cardiac disease
 Myocardial ischemia (unstable angina)
• Interval between MI time and surgery less than 6 mo. is more
likely with reinfarction
 Congestive heart failure
 Valvular heart disease (aortic stenosis, mitral valve prolapse)
 Cardiac dysrhythmias
Neurologic System
 The patient's ability to answer health history
questions practically ensures a normal mental status

 (exclude the presence of increased intracranial

pressure, cerebrovascular disease, seizure history,
pre-existing neuromuscular disease, or nerve
injuries).
Factors associated with increased
risk for aspiration
1. Recent food intake
2. Elderly patient
3. Decreased consciousness
4. Increased intragastric pressure
5. Gastric and intestinal hypomotility
6. Impaired esophageal sphincter control
7. Presence of NGT
8. Pregnancy
 Physical Examination

 Mouth and Oral cavity

 Extent of symmetry of mouth opening
 Health of teeth
 Presence of dental appliances
 Size of the tongue
 Palate
 Physical Examination

 Thyromental distance
 Tracheal deviation
 Range of Motion of head and neck
Pulmonary System
 Inspection
 Symmetry, deformities
 Chest retractions
 Palpation
 Chest expansion
 Tactile fremitus
 Percussion
 Auscultation
 Breath sounds
 Adventitious sounds
Cardiovascular System
 Inspection
 Precordium
 Palpation
 Point of maximal impulse
 Thrills
 Percussion
 Approximate size of the heart
 Auscultation
 Heart sounds
 Murmur
Physical Examination

1. Airway
2. Cardiovascular
3. Pulmonary
Airway
 The basic concern of the anesthesiologist is always the patient’s
airway.
 Evaluation of the airway involves:
1. determination of the thyromental distance,
2. the ability to flex the base of the neck and extend the head, and
3. examination of the oral cavity including dentition.
Components of the Airway Physical
Examination
Airway Examination Component
Visibility of uvula
Shape of palate
Compliance of mandibular space
Thyromental distance
Length of neck
Thickness of neck
Range of motion of head and neck
Findings Suggestive of Difficult Intubation
Not visible when the tongue is protruded
with the patient in the sitting position
Highly arched or very narrow
Stiff, indurated, occupied by a mass, or
nonresilient
<3 finger breadths
Short neck
Thick neck
Patient cannot touch the tip of the chin to
the chest or is unable to extend the neck
ASA Physical Status Classification
ASA Disease State Mortality Rate
Class
No organic, physiologic, biochemical, or psychiatric 0.06 - 0.08%
1 disturbance
Mild to moderate systemic disturbance that may not be 0.27 - 0.4%
2 related to the reason for surgery
Severe systemic disturbance that may or may not be 1.8 - 4.3%
3 related to the reason for surgery
Severe systemic disturbance that is life threatening with 7.8 - 23%
4 or without surgery
Moribund patient who has little chance of survival but is 9.4 - 51%
5 submitted to surgery as a last resort (resuscitative effort)
or
A moribund patient who is not expected to survive 24
hours with or without surgery

A brain-dead patient whose organs are being harvested)

6
E = Emergency
 MALLAMPATI CLASSIFICATION
- standard of assessing the relationship of the tongue size relative to the
oral cavity

Class Direct Visualization, Laryngoscopic

Patient Seated View

I soft palate, fauces, Entire glottic

uvula, pillars

II soft palate, fauces, Posterior

uvula commissure

III Soft palate, uvular base Tip of

epiglottis

IV Hard palate only No glottal

sturctures
Pulmonary
 RR
 Chest excursion
 Use of accessory muscles
 Nail color
 Patients abilty to carry on a conversation or to
walk without dyspnea
 Auscultation
Pulmonary Disease
 The site and type of surgery (thoracic and upper
abdominal surgery) are the strongest predictors of
pulmonary complications.
 Duration of anesthesia is a well-established risk factor
for postoperative pulmonary complications, with
morbidity rates increasing after 2 to 3 hours.
Cardiovascular
 Auscultation of the heart (murmur radiating to
the carotid arteries)
 Bruits over the carotid arteries
 Peripheral pulses
Informed Consent

 Anesthetic plan
 Alternatives
 Potential complications
Anesthesia Plan
 NPO status
 Anesthesia techniques
 Pre-medications
 Post-operative recovery
 Post-operative pain control
Pre-operative Nothing by Mouth (NPO)
Orders
 Guidelines for NPO status

Age Solids Clear liquids

<6 mos. 4° 2°
6 - 36 mos. 6° 3°
3 - 6 yr. 8° 3°

6 years or older:
NPO after midnight or at least 8 hours prior to arrival time.
F. Fasting Before Elective Surgery
Patient Characteristics Associated with Increased Risk for
Aspiration
Elderly
Decreased consciousness
Increased acid production
Gastric and intestinal hypomotility
Recent food intake
Impaired esophageal sphincter control
Neuromuscular incoordination
Presence of a nasogastric tube
Pre-operative Laboratory Evaluation
 Hemoglobin or Hematocrit
 All menstruating women
 All patients over 60 years of age
 All patients likely to experience significant blood loss and may
require transfusion
 Serum Glucose and Creatinine
 All patients over 60 years of age
 Diabetic patients
 Specific clinical indications
Pre-operative Laboratory Evaluation
 Electrocardiogram (ECG)
 All patients over 40 y.o.
 All patients with specific indications – HPN, palpitations, previous MI
 Chest Radiograph
 All patients over 60y.o.
 Specific clinical indications
 HPN, malignancy, acute pulmonary symptoms
Drug Classes for Premedication
Benzodiazepines
Opioids
Antihistamines
Anticholinergics
Histamine receptor antagonists
Antacids
Proton Pump Inhibitors
Antiemetics
Gastrokientics
A2-adrenergic agonists
 Primary Goals of Pharmacologic
Premedication
Anxiolysis Attenuation of SNS reflex
Sedation Decrease in anesthetic
requirements
Analgesia Prophylaxis against allergic
reactions
Amnesia
Antisialogogue effect
Increase in gastric fluid pH
Decrease in gastric fluid
volume
 Secondary Goals of Pharmacologic Premedication

Decrease in cardiac vagal activity

Facilitation of induction of anesthesia
Postoperative analgesia
Prevention of postoperative nausea and vomiting
 Determinants of Drug Choice and Dose

Patient age and weight

Physical status
Level of anxiety
Tolerance of depressant drugs
Previous adverse experience with drugs used for preoperative
medication
Allergies
Elective or emergency surgery
Inpatient or outpatient surgery