PRE OPERATIVE ASSESSMENTS
OF PATIENTS
Anthony Nyerges, M.D.
Clinical Professor
Department of Anesthesiology
PRE OPERATIVE ASSESSMENTS
OF PATIENTS
• Is the patient in optimum condition for surgery?
• Stressors of surgery:
– Cardiac
– Pulmonary
– Endocrine
– Neurological
– Metabolic
PRE OPERATIVE ASSESSMENTS
OF PATIENTS
• AS A CONSULTANT, THE QUESTION
ASKED IS: “FOR THIS PATIENT, ARE THE
MEDICAL CONDITIONS AS GOOD AS
THEY CAN BE?”
PRE OPERATIVE ASSESSMENTS
OF PATIENTS
• Specific recommendations for the situation
at hand:
– Hypotension: use Dobutamine infusion
– Hypertension: use ACE-I, not a CCB
– For post operative ventilation use reverse
I: E mode on ventilator
PRE OPERATIVE ASSESSMENTS
OF PATIENTS
• Recommendations such as: “Avoid
hypotension, hypoxemia, hypothermia” are
not useful.
• Recommendations such as “Avoid excess
general anesthetics and narcotics” are not
useful.
PRE OPERATIVE ASSESSMENTS
OF PATIENTS
• Physical examination:
– Venous access issues
– Arterial access: radial, femoral
– Airway / neck for ease of laryngoscopy,
necessity of fiberoptic intubation
PRE OPERATIVE ASSESSMENTS
OF PATIENTS
• Chest for vital capacity effort and baseline
breath sounds
• Cardiac murmurs, JVD, baseline pressures
• Regional anatomy: spine
PRE OPERATIVE ASSESSMENTS
OF PATIENTS
• Baseline CBC, Electrolytes, TFT
• Baseline CXR (over 50)
• Basline EKG (over 40)
PRE OPERATIVE ASSESSMENTS
OF PATIENTS
• Specialized cardiac evaluations for compromised
functions:
– Ischemia: Dobutamine stress, nuclear perfusion
(myoview), angiography, TEE for SWMA’s or
valve dysfunction.
PRE OPERATIVE ASSESSMENTS
OF PATIENTS
• Specialized cardiac evaluations for compromised
functions:
– Exercise tolerance / intolerance
– Current medications and historical use pattern;
anticoagulation issues
PRE OPERATIVE ASSESSMENTS
OF PATIENTS
• Specialized pulmonary evaluations:
– Resting ABG for obliterative disease
– PFTs for specific FEF 25-75, DLCO, lung
volumes for post-anesthetic implications
– CXR, CT scanning for pulmonary embolism,
prior resections, effusions
PRE OPERATIVE ASSESSMENTS
OF PATIENTS
• Neurological evaluations:
– Myogenic dysfunction (post CVA, Hypotonia,
Atrophy, NM junction)
– Seizures, LOC, ICP issues
PRE OPERATIVE ASSESSMENTS
OF PATIENTS
• Endocrine Dysfunction:
– Diabetes: brittle control, Hgb A1C, Hx
Hyperosmolarity, Lactic Acidosis
– Thyroid crisis: goiter, thyroid storm, low T3
states
– Parathyroid: calcium metabolism on
myocardial function, NMJ function
PRE OPERATIVE ASSESSMENTS
OF PATIENTS
• Endocrine Dysfunction:
– Adrenal: Use of intraoperative steroids and
wound healing, Hyperglycemia
– Special TPN Issues: Hepatic clearances and
myogenic functionality
PRE OPERATIVE ASSESSMENTS
OF PATIENTS
• Low concentrations of potent inhaled vapors
decrease reflexes, diaphragmatic activity
• NM antagonists increase nicotinic tone
• Sympathetic / parasympathetic “reset” BP
control, peristalsis, temperature
PRE OPERATIVE ASSESSMENTS
OF PATIENTS
• Opiate effects on sedation, cough reflex,
sympathetic control
• LMWH effects on post regional anesthesia
PRE OPERATIVE ASSESSMENTS
OF PATIENTS
• 33 y.o. male C5 quadriplegia x10 years, OSA
syndrome, Hx Ileal conduit, wheelchair
dependent
• Revision of tracheostomy in past
• Hx of sweating post prandial
PRE OPERATIVE ASSESSMENTS
OF PATIENTS
• Scheduled for new Ileal conduit diversion
• “Anesthesia: Choice”
PRE OPERATIVE ASSESSMENTS
OF PATIENTS
• No PFTs performed
• No ABG performed
• No evaluation of autonomic dysreflexia
• No thyroid functions
• No airway exam
PRE OPERATIVE ASSESSMENTS
OF PATIENTS
• Fiberoptic emergency intubation
• Hyper / hypotensive crises
• Femoral arterial access
• “Unanticipated” ICU stay, 3-day intubation,
postoperative pulmonary and cardiology
consultations
PRE OPERATIVE ASSESSMENTS
OF PATIENTS
• 86 y.o. male with mechanical fall: femoral neck fracture
• “VIP” status
• Hx or myocardial infarction s/p stents (3 years ago)
• Hx of A-Fib in past
• Hx diastolic dysfunction of TTE study
• Anticoagulated on coumadin
PRE OPERATIVE ASSESSMENTS
OF PATIENTS
• #1 ECG in EMC yields 1º AVB
• #2 ECG 1 hour later yields new LBBB
• HCT = 32, but dehydrated!
• Mild dyspnea on prior walking
• Surgery wishes to proceed urgently
PRE OPERATIVE ASSESSMENTS
OF PATIENTS
• No regional technique possible
• Awake arterial line
• Central venous cordis sheath
• Transfusion 4 units PRBC
• Post operative mechanical ventilation (Dynamic
Compliance Poor)
PRE OPERATIVE ASSESSMENTS OF PATIENTS
Case Scenario
29 y.o. male history of aplastic anemia ANC 0.1 on GMCSF
followed by hematology oncology awaiting BMTx (XRTx +
chemo preconditioning). Now with fibrous cyst of tongue
with exfoliation scheduled for hemiglossectomy. Arrives in
PTU for surgery:
• No information from Hem-Onc
• Case delayed
• Post operative wound care
• Reverse isolation environment
PRE OPERATIVE ASSESSMENTS OF PATIENTS
Case Scenario (cont.)
29 y.o. male history of aplastic anemia ANC 0.1 on GMCSF
followed by hematology oncology awaiting BMTx (XRTx +
chemo preconditioning). Now with fibrous cyst of tongue
with exfoliation scheduled for hemiglossectomy. Arrives in
PTU for surgery:
• Antibiotic, antiviral, antifungal prophylaxis
• Use of nitrous oxide
• Postoperative “bone pain” issue-GMCSF vs. operative site
• Immune effects of opiates
PRE OPERATIVE ASSESSMENTS
OF PATIENTS
• 63 y.o. Psychologist C1 – C2 fracture
• Admitted 2 ½ weeks
• “Acute” delirium unknown cause
• Chronic alcoholism
• Hyponatremia, anemia, cachexia
• ? R Lobar infiltrate
PRE OPERATIVE ASSESSMENTS
OF PATIENTS
• No cranial imaging studies
• No workup of hyponatremia
• Intraoperative fiberoptic intubation
• Intraoperative bronchoscopy
• Post operative mechanical ventilation
• Recommend CSF puncture and workup