PREOPERATIVE

EVALUATION
MARY DIANE Z. ISMAEL
Clinical Clerk
July 23, 2019
 Pre-operative Evaluation

• process of clinical assessment that precedes the

delivery of anesthesia care
• done by anesthesiologist
• consists medical records, interview, physical
examination, and findings from medical tests
and evaluations.
 Preoperative Evaluation
Is the initial step in the preparation of a patient for
the operating room.
Goals:
1. Reduce patient risk and the morbidity of surgery
2. Promote efficiency and reduce costs
3. Increasing resource utilization
PRIMARY GOAL: To formulate an anesthetic plan to
minimize risk and maximize quality of recovery
 Objectives of Preoperative
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
 American Society of
Anesthesiologists
(ASA)
• Interview with patient of guardian
• Physical examination
• Indicated diagnostic testing
• Review of diagnostic data
• ASA physical status score (ASA-PS)
• Anesthesia plans
PRE-OPERATIVE EVALUATION

MUST INCLUDE
A. Indication for the Surgical Procedure
B. Response to previous anesthetics
C. Medications/Allergies including herbal
medications
1. Review the database
1. Review the database

Pre-operative History Taking

Goals:

• Inform the patient of the risk

• Educate the patient regarding the anesthesia and events to take place in
the pre, peri-, and post operative period
• Answer questions and reassure the patient and family
• Notify NPO status
• Instruct the patient about which medications to take on the day of
surgery or which medications to stop taking
• Final: use the operative experience to motivate patient to more optimal
heath and improved health outcomes
1. Review the database

PREANESTHESIA
HISTORY
• Planned procedure
• Past anesthetic history with
review of complications
• Comorbid conditions
• Assessment of allergies and
medications
• Documentation of substance use
or abuse
• Last oral intake if done on the day
of surgery
• Others:
• Severity of disease
• efficacy of treatment, and impact
1. Review the database

Pre-operative Evaluation

 Three aspects of  Three aspects of

acute history chronic history  Three aspects of
1. History of 1. Medications physical
present illness 2. Social history examination
2. Exercise 3. Past medical & 1. Airway
tolerance family history 2. Cardiovascular
3. Patient’s visits 3. Pulmonary
to his physician
 Current Drug Use and Potential Interactions with Drugs
Administered in the Perioperative Period
Drug Adverse Effects

Alcohol Abuse Tolerance to anesthetic drugs

Beta-Antagonists Bradycardia, Bronchospasm, Impaired sympathetic

nervous system responses, Myocardial depression
Antibiotics Prolongation of the effects of neuromuscular blocking
drugs
Antihypertensives Impaired sympathetic nervous system responses

Aspirin Bleeding tendency

Benzodiazepines Tolerance to anesthetic drugs

Calcium channel blockers Hypotension

Digitalis Cardiac dysrhythmias or conduction disturbances

 Current Drug use and Potential Interactions with Drugs
Administered in the Perioperative Period

Drug Adverse Effects

Diuretics Hypokalemia, Hypovolemia

Monoamine Oxidase Exaggerated responses to sympathomimetic

Inhibitors drugs if previous treatment was acute

Tricyclic Exaggerated responses to sympathomimetic

Antidepressants drugs if previous treatment was acute
2. Perform physical
examination
 examination
. Perform physical examination

PHYSICAL
EXAMINATION
• Vital signs
• Head and Neck
• Cardiovascular
• Pulmonary
• Back
• Neurologic examination
 THREE ASPECTS OF PE

AIRWAY CARDIOVASCUL PULMONARY

AR
Airway Examination
•Always the basic concern of the
anesthesiologist
• Difficult or failed airway
management is the major factor in
anesthesia-related morbidity and
death
AIRWAY
Preoperative Patient
Characteristics
Associated With
Possible Difficult
Airway
Management
 AIRWAY EXAMINATION: MALLAMPATI
CLASSIFICATION

› Soft palate  Soft palate › Soft palate › Hard Palate

› Fauces  Fauces › base of uvula
› Uvula
› Tonsillar pillars
 Uvula
 AIRWAY EXAMINATION
Airway Examination Component
Length of upper incisors
Relationship of maxillary and
mandibular incisors during normal
jaw closure
Relationship of maxillary and
mandibular incisors during
voluntary protrusion of mandible
(ability to prognath; upper lip bite
test)
Interincisor distance
Visibility of uvula
Nonreassuring Findings
Relatively long
Prominent “overbite” (maxillary incisors
anterior to mandibular incisors)
Inability to bring mandibular incisors
anterior to (in front of) maxillary
incisors; unable to bite the upper lip
Less than 3 cm
Not visible when tongue is protruded
with patient in sitting position (e.g.,
Mallampati class II)
 AIRWAY EXAMINATION
Airway Examination
Component
Compliance of the
mandibular/oral space
Thyromental distance
Length of neck
Thickness of neck
Range of motion of head and
neck
Nonreassuring Findings
Highly arched or very narrow;
radiation or surgical changes;
stiff, indurated, occupied by mass
or nonresilient
<3 fingerbreadths or <6 cm
Short
Thick
Cannot touch tip of chin to
chest or extend neck
 CARDIOVASCULAR
Uncontrolled hypertension
Unstable cardiac disease
Myocardial ischemia (unstable
angina)
Congestive heart failure
Valvular heart disease (aortic
stenosis, mitral valve prolapse)
Cardiac dysrhythmias
• Inspection
• (precordium, veins as access
sites, peripheral edema)
• Palpation
• (point of maximal impulse,
thrills, peripheral pulses)
• Percussion
• Auscultation of the heart
• (heart rate, rhythm, murmur,
systemic blood pressure)
 PULMONARY
Tobacco use
Shortness of breath, cough,
wheezing, stridor, and
snoring or sleep apnea
- Asthma
- Obstructive Sleep Apnea
(OSA)
URTI (presence and recent
history)
• Inspection
• (respiratory rate, symmetry,
deformities, use of accessory
muscles, nail color, ability to
carry on a conversation,
pattern of breathing)
• Palpation
• (chest retractions, chest
expansion)
• Percussion
• Auscultation
• (breath sounds, adventitious
sounds)
 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.
 Investigations and testing
• ASA RECOMMENDATIONS:
• Preoperative tests should not be ordered routinely

BUT
• Preoperative tests may be ordered, required, or
performed on a selective basis for purposes of guiding
or optimizing perioperative management
 LABORATORY EXAMINATION
Preoperative Diagnostic Testing Recommendations
Albumin Anasarca, liver disease, malnutrition, malabsorption
Beta- hCG Suspected pregnancy
Alcohol abuse, anemia, dyspnea, hepatic or renal disease,
CBC malignancy, malnutrition, history of bleeding, poor exercise
tolerance, recent chemotherapy or radiation therapy
Creatinine Renal Disease, poorly controlled diabetes
Active cardiac condition, alcohol abuse, pulmonary
ECG hypertension, severe obesity, use of digoxin
Electrolyte Alcohol abuse, cardiovascular, hepatic, renal, thyroid,
s diabetes, malnutrition
Glucose Diabetes, severe obesity, steroid use
 Preoperative Diagnostic Testing Recommendations

LFTs Alcohol abuse, hepatic disease, undiagnosed bleeding disorder

Platelet
Bleeding disorder, hepatic disease, hematologic malignancy
count

PT Bleeding disorder; use of warfarin

Bleeding disorder, undiagnosed hypercoagulable state, use of

PTT unfractionated heparin

TSH, T3,
Goiter, thyroid disease, unexplained dyspnea, palpitations
T4

Urinalysis Suspected UTI

 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
• Other 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
 ANESTHESIA-PATIENT RELATIONSHIP

• Organized interview
• Reassuring the patient
• Events of the perioperative period:
• NPO status
• Estimated time of surgery
• Need for premedication
• Post-operative recovery
• Plans for postoperative pain control
5. MAKE AN ANESTHESIA
PLAN
 FORMULATION OF AN
ANESTHETIC PLAN
• Risk Assessment and Informed Consent
• Anesthesia techniques
• Medications
• Pre-medications
• Post-operative recovery
• Post-operative pain control
• Fasting Guidelines
 Commonly Disclosed Risks of
GENERAL Anesthesia
Frequently Occurring Infrequently occurring
Minimal Impact Severe impact
• Oral or dental damage • Awareness
• Sore throat • Visual loss
• Aspiration
• Hoarseness
• Organ failure
• Postoperative • Malignant hyperthermia
nausea/vomiting • Drug reactions
• Drowsiness/confusion • Failure to wake up/recover
• Urinary retention • Death
 Commonly Disclosed Risks of
REGIONAL Anesthesia
Frequently Occurring Infrequently occurring
Minimal Impact Severe impact
• Bleeding
• Prolonged • Infection
numbness/weakness • Nerve damage/paralysis
• Post–dural puncture • Persistent numbness/weakness
headache • Seizures
• Failure of technique • Coma
• Death
 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
 B. Anesthesia Techniques

• General Anesthesia
• Inhalational
• TIVA
• Regional Anesthesia
• Epidural anesthesia
• Sub-arachnoid block
• Caudal anesthesia
• Peripheral Nerve Block
 Considerations That Influence the
Choice of Anesthetic Technique
Patient Factors
• Coexisting diseases
• Risk of aspiration
Procedural Factors
• Age of the patient
• Patient cooperation
•• Site of the surgery
Anticipated ease of airway management
•• Operative
Coagulation technique
status (e.g., laparoscopic versus open
Logistical Factors
approach)
• Previous response to anesthesia
•• Position
Preferenceof the patient
of the during surgery
patient
••Postoperative disposition
Duration of surgery
• Postoperative analgesic plan
• Equipment availability (e.g., ultrasound)
 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
 Drug Classes for Premedication

Benzodiazepines Antacids
Opioids Proton Pump Inhibitors
Antihistamines Antiemetics
Anticholinergics Gastrokientics
Histamine receptor A2-adrenergic agonists
antagonists
 Primary Goals of Pharmacologic
Premedication
Anxiolysis Attenuation of SNS reflex
SedationSecondary Goals of Decrease in anesthetic
Pharmacologic
requirements
Premedication
Analgesia Prophylaxis against
Decrease in cardiac vagal activity
allergic reactions
Facilitation of induction of anesthesia
Amnesia
Postoperative analgesia
Antisialogogue effect
Prevention of postoperative nausea and vomiting
Increase in gastric fluid
pH
Decrease in gastric fluid
volume
 Fasting guidelines
Ingested Food Minimum Fasting Period
(for all ages)
Clear liquids (water, pulp-free juices, 2 hours
carbonated beverages, clear tea, black
coffee)
Breast milk 4 hours
Infant formula 6 hours
Non-human milk 6 hours
Light meal ( toast and clear liquids) 6 hours
Full Meal >8 hours
Thank you.