PRE-OPERATIVE

ASSESMENT OF PATIENTS

N I K H I L PA N J I YA R ( I N T E R N )
1 S T B AT C H
BMC

MODERATOR : DR.ROSHAN PRADHAN.

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 Contents
•Objectives

•Introduction

•Goals

•Steps of preoperative visit

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 Objectives
•Evaluate the patient’s medical condition

•Optimise the patient’s medical condition

•Determine and minimize risk factors for anesthesia

•Plan anesthetic technique & perioperative care

•Facilitate conduct of anesthesia

•Inform and educate the patient & consent

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PREOPERATIVE ASSESMENT
INTRODUCTION

•Process of clinical assessment

•Preceding the delivery of anesthesia for surgery and for non surgical
procedures

•Patient’s interview, medical records, physical examination and findings

from medical tests and evaluations

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 GOALS

• To ensure that the patient is in the best(optimal) condition.

• Unstable symptoms should be postponed for optimization prior to elective

surgery.

• Focused review of all major organ system should be done prior to elective
surgery.

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STEPS OF PREOPERATIVE
VISIT

1. Problem identification

2. Risk assessment

3. Preoperative preparation

4. Plan of anesthetic technique.

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 PROBLEM
IDENTIFICATION
•Case history

•Physical examination

•Laboratory investigations

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 Case History

• Demographic details
• Presenting complaint
• History of presenting complaint
• Past medical history
• Previous anesthetic history
• Drug history
• Systemic enquiry

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 Physical examination

•General and local examination

•Evaluation of : upper airway special examination : airway assessment

respiratory system peripheral access

cardiovascular system spine examination

vitals sign

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 Airway

•Difficult airway : Conventionally trained anesthesiologist

experiences difficulty with face mask ventilation or tracheal
intubation or both

•Evaluation is the first step in management of difficult

intubation.

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 AIRWAY CLASSIFICATION SYSTEM

MALLAMPATI SCORE

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DIRECT LARYNGOSCOPIC VIEW
COOK MODIFICATION

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 Airway evaluation
• Mentothyroid distance : normal 6 cm.

• Mentosternal distance : normal 15 cm

• Mentohyoid distance : normal 3 FB

• Neck movement

• Nasal cavity

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 Airway Examination
NORMAL
•Opens mouth normally (Adults: greater than 2 finger widths or 3 cm)
•Able to visualize at least part of the uvula and tonsillar pillars with
mouth wide open & tongue out (patient sitting)
•Normal chin length (Adults: length of chin is greater than 2 finger
widths or 3 cm)
•Normal neck flexion and extension without pain / parasthesias

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 Difficult intubation
• Interincisor distance less than 3 cm.
• Limitation of neck movement
• Micrognathia
• Macroglossia
• Thyromental distance less than 6 cm
• Protusion of teeth
• Short neck
• Morbid obesity

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 Patient assessment

•ASA physical status

•Cardiac risk :

1. Goldman’s multifactorial cardiac risk assessment

2. Detsky’s multifactorial index

3. Revised cardiac index

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 Pulmonary Disease
•Pulmonary complications occurs more frequently than cardiac complications
(5-10% incidence )
•Perioperative complications includes:
1. Aspiration
2. Atelectasis
3. Pneumonia
4. Bronchospasm
5. Hypoxemia
6. Acute exacerbation of COPD
7. Respiratory Failure requiring Mechanical Ventilation

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 Pre-operative Investigations
• General:
1. Complete Blood Count
2. Clotting screen
3. Liver function
4. ECG
5. Echocardiogram
6. Chest x-ray
7. Blood sugar level
8. Electrolytes, Blood Urea Nitrogen/ Creatinine

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 RISK ASSESSMENT
Components for evaluating perioperative risk

1. Patient medical condition preoperatively

2. Type or extent of surgical procedure

3. Risk from anesthesia

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 Preoperative Preparation
ANESTHETIC INDICATION
•Anxiolysis, sedation and amnesia: Benzodiazepam
•Analgesia: narcotics
•Drying of airway secretions e.g. atropine, glycopyrrolate
•Reduction of anesthetic requirements
•Facilitation of smooth induction
•Patients at risk for GE reflux : ranitidine,metoclopramide , sodium
citrate

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

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CO-EXISTING DISEASE INDICATION
•Some medications should be continued on the day of surgery
•Others are stopped
•Steroids within the last six months may require supplemental steroids

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 Medication to be continued on the day of
surgery.
1. Antihypertensives except ACE Is and ARBs

2. Cardiac medications e.g B-blockers, digoxin

3. Antidepressants, anxiolytics

4. Thyroid medications

5. Birth control pills, eye drops, heartburn or reflux medications,

narcotics, anticonvulsants, asthma medications, Steroids, Statins

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 Medications to be discontinued
•Topical medications e.g creams and ointments

•Oral hypoglycemic agents (metformin) 3 days before and switch to

insulin

• Diuretics on the day of surgery

• Sildenafil or similar drugs – discontinue 24 hrs prior to surgery

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•NSAIDS – discontinue 48 hrs before surgery

•Warfarin ( Coumadin) discontinue 4 days before surgery

• lithium : 48-72 hrs prior to surgery.

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•Antiplatelet agents like clopidogrel and conventional
dose of aspirin should be stopped 7 days before
surgery

•Low dose of aspirin can be continued till the date of

surgery

•Clopidogrel can be continued in cataract surgery

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 NPO guidelines

Substance Maximum Hours of Fasting

Solid 8

Formula 6

Cow milk 6

Citrus juice 6

Breast milk 4

Clear liquid 2

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 Antibiotic Prophylaxis
•Cephalosporins are the most popular antibiotics because they cover
skin microbes,

•For intestinal surgery , anaerobic and Gram negative coverage is

needed.

•when tourniquet is used, the antibiotics should be administered prior to

its inflation.

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 Psychological Preparation
Preoperative visit and interview with the patient and family members,
• The anesthesiologist should explain anticipated events and the
proposed anesthetic management in an effort to reduce anxiety and
diminish apprehension.

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 PLAN OF ANESTHESIA
TECHNIQUE
• Local

• Regional anesthesia

• General anesthesia

• Combination.

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 REFERENCES
•Marino’s ICU book – 4th edition

•Short text book of anesthesia by Ajay yadav- 6th edition

•Zambouri A. Preoperative evaluation and preparation for anesthesia and

surgery. Hippokratia. 2007;11(1):13-21.

•Google for images

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 Thank You 

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