Pre-operative
Preparation
• Supervised By: A Prof Dato Nik
Shukri
• Presented By:
• Hu Jingyang (0129220120707)
• Rumalsraj (1129200919641)
• Tuan Nur Syahirah Amani
(1129200919460)
• Sri Amelia Natasha
(1129200919455)
Definition of Preoperative Assessment:
Preoperative assessment is a systematic evaluation of a patient's health status before
undergoing surgery. It involves reviewing medical history, performing physical
examinations, assessing risks, and planning perioperative care to optimize outcomes.
Purpose of Preoperative Assessment:
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Ensure patient safety by identifying potential risks and comorbidities.
Optimize the patient’s medical condition before surgery.
Develop an individualized care plan for anesthesia and surgery.
Reduce the risk of surgical complications and delays.
Enhance communication among surgical, anesthesia, and nursing teams.
Inform and educate the patient about the surgical procedure and recovery.
History taking, Physical
Examinations and Investigations
RUMALSRAJ
History Taking
• Demographics
• Age: >65 years has increased surgical
risk
• BMI: underweight or overweight;
related to poor nutritional reserve,
difficult intubation or thromboembolic
risk
• Past Medical History; cardiovascular,
respiratory, endocrine, renal, hepatic,
neurological, hematologic
• Prior Surgical and Anaestheticrelated complications
• Fasting status; prevent aspiration
during induction of anaesthesia
• Solids: 6 hours, Clear fluids: 2 hours
• Allergies; prevent life-threatening
anaphylaxis or delayed allergic
reactions
• Drugs: penicillin, NSAIDs, opioids
• Latex
• Anaesthetic agents: previous reactions
(malignant hyperthermia, nausea)
• Contrast dyes
• Seizure
• May need AED
perioperatively
Past Medical History
System
Ask for signs or symptoms
Reasons
Cardiovascular
Chest pain (angina), dyspnea on exertion or at rest,
palpitations, syncope or dizziness
Risk of perioperative MI, arrhythmias, or cardiac arrest
May require ECG, Echo, cardiology clearance
Respiratory
Chronic cough, shortness of breath, wheezing, sputum Increases risk of post-op pneumonia, hypoxia, bronchospasm
production, smoking history
May need CXR or PFT
Endocrine
Diabetes: polyuria, polydipsia, poor wound healing,
numbness
Thyroid: weight change, palpitations, cold/heat
intolerance
Poor control affects healing, infection risk, glycemic control
under GA
Thyroid dysfunction affects metabolic response
Renal
Oliguria, anuria, nocturia, swelling (edema), history of
dialysis
Impaired drug clearance, fluid overload risk
May need dose adjustments, nephrology input
Hepatic
Jaundice, easy bruising, fatigue, alcohol history
Impaired clotting, hypoalbuminemia, drug metabolism issues
May need coagulation studies
Neurological
History of stroke, TIA, seizures, weakness or
numbness, cognitive impairment
Stroke risk, aspiration risk, altered mental status impacts
consent and recovery
Hematologic
Easy bruising/bleeding, history of DVT/PE, anemia
symptoms (fatigue, pallor)
Risk of surgical bleeding or thromboembolism
May need FBC, coagulation profile, thromboprophylaxis
Surgical or
Anaesthesia History
• Past surgeries: what type of
surgery done, when, any
complications
• Anaesthesia: difficulty
intubation, nausea/
vomiting, delayed walking
• Blood transfusion history
(Asking these can predict
future complications)
Social History
• Smoking; increase risk of chest
infection and delayed healing
• Alcohol; risk of withdrawal, liver
disease, coagulopathy
• Recreational drugs use; may
interfere with anaesthetic
metabolism
• Functional status; assess with
METs score for risk stratification
Drug History
Drug Class
Anticoagulants (warfarin, apixaban, enoxaparin,
clopidogrel)
Concern
Antiplatelets (aspirin, clopidogrel)
May need to stop depending on procedure
Antihypertensives (beta-blockers, ACEi/ARB, CCBs)
Risk of hypotension, continuation plan
Diabetes meds (insulin, metformin, sulfonylureas)
Adjust dosing; metformin stopped 24-48h before GA
Steroids (prednisolone)
Psychotropics (antidepressants, antipsychotics)
Anti-epileptics
Inhalers (salbutamol, ipratropium, steroids)
Herbal/supplements (ginseng, ginkgo, garlic)
Bleeding risk, need to stop or bridge
Risk of adrenal insufficiency – may need stress
dosing
Interaction with anesthesia; serotonin syndrome
risk
Ensure compliance; prevent periop seizures
Ensure availability and use pre-op
Can affect bleeding, BP, drug metabolism
Physical Examination
General
• Vital signs; HR, BP, RR,
Temp., Pain score
• BMI
• Pallor; sign of anemia
• Jaundice; liver disease> risk
of coagulopathy
• Oedema; CCF, CKD, CLD
• Lymphadenopathy; suspect
for malignancy
• Hydration status
• Cardiovascular
• Murmur (AS has higher anaesthetic risk)
• Rate/rhythm
• JVP elevation: CCF or fluid overload
• Peripheral pulse; indicative of poor
circulation -> PAD(affects wound healing)
• Respiratory
• Breath sounds
• Wheeze: asthma/COPD
• Crackles: pulmonary edema or infection
• Percussion; dullness -> effusion or
consolidation
Physical Examination
• Neurological
• Orientation, GCS; able to
get consent or risk of postop delirium
• Motor/Sensory
• Pre-existing deficits;
medico-legal
• Paralysis from stroke; risk of
aspiration
• Surgical site examination
• Signs of infection; redness,
warmth, discharge> may
need to postpone surgery
• Mass or hernia
• Skin condition; rashes or
ulcers> risk of infection
Investigations
Test
Purpose
Ask/Check
Full Blood Count (FBC)
Detect anemia, infection,
thrombocytopenia
Hb <10 g/dL may need delay/transfusion
Renal Profile (U/E/Cr)
Assess kidney function, risk of electrolyte
Uremia, ↑Creatinine → adjust meds
imbalance
Random Blood Sugar / HbA1c
Glycemic control
RBS >10 mmol/L or HbA1c >8% = high risk
Liver Function Tests (LFT)
Assess synthetic function, bilirubin
↑AST/ALT, ↓Albumin, ↑INR →
coagulopathy risk
Coagulation Profile (PT, APTT,
INR)
Detect bleeding risk
Needed before central lines, spinal blocks
Blood Group & Crossmatch
Prepare blood products
For transfusion if needed
Urine Tests
Detect UTI
For women of reproductive age
Urinalysis
Urine pregnancy test
Imaging
CXR, ultrasound, CT/ MRI, angiogram
Assess cardiac risk
Indication: Canadian Cardiovascular Society (CCS) Guidelines recommend cardiac risk
assessment in patients over the age of 45 or patients 18 to 44 with significant
cardiovascular disease.
Risk factor: Clinical risk factors for a perioperative major adverse cardiac event (MACE)
include the following:
• Reduced functional status (< 4
• Significant arrhythmias (Mobitz II AV block,
METs)
3rd-degree block, symptomatic ventricular
• Ischemic heart disease (history of
arrhythmia, symptomatic bradycardia, newly
MI, angina pectoris, etc.)
recognized ventricular tachycardia)
• Heart failure
• Chronic renal failure
• Cardiomyopathy
• History of cerebrovascular accident or
• Severe valvular heart disease
transient ischemic attack
(severe aortic stenosis, symptomatic • Diabetes mellitus requiring Insulin
mitral regurgitation)
• Obesity
• Chronic pulmonary dysfunction
• Anemia
Metabolic Equivalent of
Task
Indication: used to evaluate a patient's functional
capacity and risk for perioperative complications,
particularly cardiovascular events.
METs represent the ratio of an individual's working
metabolic rate to their resting metabolic rate, with
one MET equivalent to the resting oxygen
consumption. A patient's ability to perform multiple
METs indicates their ability to handle the physical
demands of daily activities and surgery.
Preparation for cardiac assessment
Electrocardiogram
• to assess for the possibility of myocardial ischemia, left ventricular hypertrophy, conduction
blocks or other arrhythmias.
• ECG is recommended only for;
• Patient with no sign and symptoms of heart disease who about to undergo surgery with high
cardiac risk
• Patient with more than 1 cardiac risk who are about to undergo intermediate risk procedure
• Patient clinical manifestation of cardiac ischemia, arrhythmia, valvular heart disease,
congenital heart anomalies, or congestive heart failure.
Echocardiography
• Not a routine
• Indicated:
• Dyspnea of new onset
• Congestive heart failure with worsen symptoms over the past 12 months
• Heart murmurs
3. Non-invasive stress test
• Not a routine part of preoperative evaluation
• In study show moderate to large areas of inducible
ischemia on noninvasive stress testing have been
shown to be a predictor of a major adverse cardiac
event
• Based on the ACC/AHA class IIa recommendations,
physicians can consider noninvasive stress testing in
patients undergoing high-risk surgery, with reduced
or unknown functional capacity, if there is clinical
suspicion that it may change management.
• For these patients, either exercise-induced or
pharmacological induced stress testing is
appropriate
Indication for referral
Indication
Medical comorbidities
Abnormal investigation results
High ASA classification (≥ III)
Complex surgical procedures
Special populations (elderly,
pediatric, pregnant)
Reason for Referral
Optimize chronic conditions affecting
perioperative risk
Address findings impacting anaesthetic
management
Assess and plan for increased
perioperative risk
Prepare for specialized anaesthetic
requirements
Tailor assessment to specific physiological
needs
LED TO REASON
• Lead in: Introduce yourself and identify the patient
• Explore: How much does the patient know
• Diagnosis: Why the operation is being proposed
• Treatment: Explain whether the treatment proposed is in
accordance with protocols
• Options: Discuss all the options including that of doing nothing.
Taking a
Comprehensive • Results: Explain likely outcome in terms of pain, mobility, work,
diet and return to normal activities.
Consent
• Eventualities: For example, the possibility of needing to remove
the testicle in a hernia operation.
• Adverse events: Myocardial infarction, stroke, bleeding and
specific damage.
• Sound mind: Ask if they have understood
• Open question: Check if further clarification is needed
• Notes: Document everything discussed and agreed
Patient Preparation
• Both the operating surgeon and the anaesthetist should see the patient prior to
surgery.
• The patient’s identity and the proposed surgery should be confirmed.
• After explaining the risks and benefits to the patient, valid consent for surgery
should be obtained.
• Check made for any contraindications to elective surgery, e.g. undercurrent illness
or remote site infection.
• Check that all relevant results and imaging are available.
• Check that the side or area to be operated on is marked with an arrow at or near
to the incision site.
Theatre team preparation
• The theatre list should have a header with the date, time and details of the theatre,
surgeon and anaesthetist.
• For each operation, the patient’s name and hospital number, preoperative ward,
operation title and site of surgery should be recorded.
• Additional information may include the need for specialised equipment or implants,
instrument sets, use of a specific operating table, patient positioning, availability of blood
products.
• Priorities: infectious patients should be listed last to avoid delays from theatre
contamination. Children and diabetic patients will need to go first.
• Support services, e.g. radiology for intraoperative imaging, haematology for blood
products, cell salvage and pathology for frozen sections, should also be available.
Clinical Judgement
• Helping healthcare providers make informed decisions about a patient's
readiness for surgery and the best approach to ensure a safe and successful
outcome.
Making Informed Decisions
• Risk Assessment:
Gathering & Analyzing Data
Age, comorbidities, procedure type
• Objective Data:
• Optimization Strategies:
Lab tests, imaging, physical exams
• Adjust meds
• Subjective Data:
• Dietary changes
Patient symptoms, concerns,
• Fitness training
understanding
• Surgical Planning:
• Critical Thinking:
Choose technique, anesthesia, and timing
Analyzing all data to assess risks &
• Effective Communication:
plan care
Discuss risks, benefits, and expectations with
patients
Why It Matters?
Real-Life Examples of Clinical
Judgment
• Diabetic Patient:
Ensure well-controlled blood sugar
• History of Infection:
Evaluate for prophylactic
antibiotics
• Low Functional Capacity:
Recommend pre-op rehabilitation
1. Better Outcomes:
o Personalized care equal to fewer
complications
2. Enhanced Safety:
o Early identification of risks leads
to safer procedures
3. Evidence-Based Practice:
o Combines clinical guidelines
with provider expertise
4. Shared Decision-Making:
o Collaborative decisions
strengthen the patient-provider
relationship
References
• https://www.ncbi.nlm.nih.gov/books/NBK537146/
• https://teachmesurgery.com/perioperative/preoperative/assessment
/
• https://resources.wfsahq.org/atotw/preoperative-assessment-offunctional-capacity/
• https://www.acrosspg.com/notes/medicine/aha-and-nyhaclassification-of-stages-of-heart-failure/
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