PREOPERATIVE ASSESSMENT
Hossam M. Ajabnoor
Anesthesia & ICU Asistant Consultant
And Lecturer
School of Medicine, Taibah University
INTRODUCTION
Importance
1. Reduce patient risk and morbidity associated
with surgery and coexisting diseases
2. Promote efficiency and reduce costs
3. Prepare the patient medically and
psychologically for surgery and anesthesia
ASA basic standards for preanesthetic care
1. Determining the pt. medical status
2. Developing an anesthetic care plan
3. Reviewing with the pt. or a responsible adult
this plan
Who should perform the preoperative
evaluation?
Ideally, the preoperative evaluation is performed
by the person who will administer the
anesthetic.
Goals:
1. Inform the pt. of the risk → informed consent
2. Educate the pt. regarding anesthesia Plan
3. Answer pt. Q.s & reassure the pt. & family
4. Prohibition of ingesting food
5. Instruct the pt. about which medications to
take or to stop on the day of surgery
PREOPERATIVE EVALUATION
• It is important for the evaluation to be
complete, accurate, and clear, not only to
allow the information to be relayed to others
who may care for the patient perioperatively,
but also for medico legal purposes
COMPONANTS
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HISTORY
PHYSICAL EXAMINATION
LAB TESTS
CONSULTATIONS (if needed)
PLAN
DISCUSSION WITH PATIENT
HISTORY
1. State of health of pt. especially their
• exercise tolerance
• Present illness
2. Mental status
3. Medication and substances use(e.g., cigarettes,
alcohol)
4. Previous anesthesia and any complications
5. Drug allergies and family Hx of MH
6. review of medical records
SPECIFIC AREAS IN Hx
CNS
 Strokes - seizures
CVS
 Angina - old MI – HTN – rheumatic fever –
claudication – arrhythmias
PULMONARY
 SOB – cough/sputum – asthma – smoking –
recent UTI – pneumonia
GI
 GERD – alcohol – hepatitis
KIDNEYS
 Dialysis – ch. Renal impairment
MUSCULOSKELETAL
 Arthritis – osteoporosis – weakness
ENDOCRINE
 DM – thyroid/adrenal dysfunction
COAGULATION
 History of DVT/PE – bleeding tendency
PREGNANCY?
DENTITION
PHYSICAL EXAMINATION
1.
2.
3.
4.
Vital signs
CNS (LOC – evidence of S/M weakness)
Airway
CVS (heart sounds – BP – peripheral edema peripheral pulses – veins)
5. Lungs (rales – wheezes – breathing pattern)
AIRWAY
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Cervical spine mobility
Short thick neck
Temporomandibular mobility
Large tongue
Prominent central incisors
Diseased or artificial teeth
Thyromental distance and tissue compliance
Ability to visualize the uvula (Mallampati
classification)
Mallampati classification
Mallampati found a correlation between higher
oropharyngeal class and decreased glottic
exposure at laryngoscopy. A higher
oropharyngeal class combined with a mental
space < 2 fingerbreadths may better predict
increased difficulty with intubation
Performed by having patients in sitting position
with their mouth widely open and protruding the
tongue completely forward. (A tongue depressor
is not used)
DIRECT VISUALIZATION, PATIENT SEATED
class I → soft palate, fauces, uvula, and
pillars
class II → soft palate, fauces, and a
portion of the uvula
class III → soft palate and base of the
uvula
class IV → hard palate only
LARYNGOSCOPIC VIEW
Entire glottic
Posterior commissure
Tip of epiglottis
No glottal structures
LAB TESTS
• No evidence supports the use of routine
laboratory testing
• Use selected laboratory analysis based on the
patient's preoperative history, physical
examination, and proposed surgical procedure
Test
Indications
Electrocardiogram
Cardiac and circulatory disease, respiratory
disease, advanced age†
Chest radiograph
Chronic lung disease, history of congestive heart
disease
Pulmonary function tests, including blood
gas analysis and spirometry
Reactive airway disease, chronic lung disease,
restrictive lung disease (e.g., scoliosis)
Hemoglobin/hematocrit
Advanced age,† anemia, bleeding disorders, other
hematologic disorders
Coagulation studies
Bleeding disorders, liver dysfunction,
anticoagulants
Serum chemistries (Na+, K+, Cl-, CO2, glucose) Endocrine disorders, medications, renal
dysfunction
Pregnancy test
Uncertain pregnancy history, history suggestive of
current pregnancy
CONSULTATIONS
Preoperative consultations fall into two general
categories:
• Those cases that need more information or expertise
to establish or quantify a diagnosis that has
implications for anesthetic management. An example is
asking a cardiologist to evaluate a 50-year-old man
with recent onset of exertional chest pain.
• Patients in whom the diagnosis is known, but further
evaluation and treatment are needed to optimize their
medical condition prior to surgery. Referring patients
with poorly controlled diabetes, hypertension, or
asthma to an internist are examples.
PLAN
Type of anesthesia
• Awake
• Sedation
• Local
• Regional
• General anesthesia
Transfer postop
• Home
• Hospital room (day care / ward)
• ICU
Pain control postop
Discussion With The Pt. Preop
1. Risks related to anesthesia
• Nausea and vomiting
• Myalgia
• Dental injury
• Peripheral neuropathy
• Cardiac dysrhythmias
• Atelectesis
• Aspiration
• Stroke
• Allergic drug reactions
• Death (very unlikely)
2. Preop insomnia and its treatment
3. Time, route of administration & effects of
preop meds
4. Time of transport to OR
5. Duration of surgery
6. Awakening after surgery in PACU
7. Probable presence of catheters on awakening
8. Time to expected discharge from PACU
9. Magnitude of postop discomfort and it
treatment
ASA PHYSICAL STATUS CLSSIFICATION
Created in 1940
purposes of statistical studies and hospital records
It is useful both for outcome comparisons and as a convenient means of
communicating the physical status of a patient
Unfortunately, it is imprecise, and a patient often may be placed in different
classes by different anesthesiologists
the higher ASA class only roughly predicts anesthetic risk
• Class 1: Healthy patient, no medical problems
• Class 2: Mild systemic disease
• Class 3: Severe systemic disease, but not incapacitating
• Class 4: Severe systemic disease that is a constant threat to life
• Class 5: Moribund, not expected to live 24 hours irrespective of operation
• An e is added to the status number to designate an emergency operation.
An organ donor is usually designated as Class 6.
How long should a patient fast before
surgery?
• Healthy adults with no risk factors for aspiration
include no solid food for a minimum of 6 hours,
clear liquids up to 2 hours prior to an elective
procedure, and oral preoperative medications up
to 1-2 hours before anesthesia with sips of water.
• Pediatric patients are as follows:
 clear liquids up to 2 hours preoperatively
 breast milk up to 4 hours preoperatively
 solid foods, including nonhuman milk and
formula, up to 6 hours preoperatively.
How long before surgery must A
smoker patient quit smoking?
• Carbon monoxide (CO) from cigarette smoking diminishes
oxygen delivery to tissues
• Nicotine increases heart rate and can cause peripheral
vasoconstriction
• Within 12-24 hours of discontinuing cigarettes, CO and
nicotine levels return to normal
• Bronchociliary function improves within 2-3 days of
cessation
• sputum volume decreases to normal levels within about 2
weeks
• However, there may not be a significant decrease in
postoperative respiratory morbidity until after 6-8 weeks of
abstinence.
List the major goals of premedication
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Sedation and anxiolysis
Analgesia and amnesia
Antisialagogue effect
To maintain hemodynamic stability, including
decrease in autonomic response
• To prevent and/or minimize the impact of
aspiration
• To decrease postoperative nausea and vomiting
• Prophylaxis against allergic reaction
What factors should be considered in
selecting premedication for a patient?
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Patient age and weight
Physical status
Levels of anxiety and pain
Previous history of drug use or abuse
History of postoperative nausea or vomiting or
motion sickness
• Drug allergies
• Elective or emergency surgery
• Inpatient or outpatient status
List the most commonly used preop
medications
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Diazepam Oral 5-20 Sedation
Midazolam IV 2.5-5 Sedation
Morphine IM 5-15 Analgesia
Meperidine IM 50-150 Analgesia
Ranitidine Oral, IV 150 mg and 50 mg, respectively
Decrease gastric pH
Metoclopramide Oral, IM, IV 5-20 Gastrokinetic
Glycopyrrolate IM, IV 0.1-0.3 Weak sedative, antisialagogue
Scopolamine IM, IV 0.3-0.6 Sedative, antisialagogue
Promethazine IM 25-50 Antiemetic
Ketamine IM, oral 1-2 mg/kg and 6 mg/kg, respectively
Sedation
A 3-year-old child presents for an
elective tonsillectomy. His mother
reports that for the past 3 days he
has had a runny nose. Should you
postpone surgery?
• Viral URI alters the quality and quantity of airway
secretions and increases airway reflexes to
mechanical, chemical, or irritant stimulation
• Some clinical studies have shown associated
intraoperative and postoperative bronchospasm,
laryngospasm, and hypoxia
• There is evidence that the risk of pulmonary
complications may remain high for at least 2
weeks, and possibly 6-7 weeks, after a URI
• Infants have a greater risk than older children,
and intubation probably confers additional risk
• However, as a practical matter, young children can average
5-8 URIs per year, mostly from fall through spring
• If a 4- to 7-week symptom-free interval were rigorously
followed, an elective surgery might be postponed
indefinitely
• Therefore, most anesthesiologists distinguish
uncomplicated URI with chronic nasal discharge from nasal
discharge associated with more severe URI with or without
lower respiratory tract infection (LRI)
• Chronic nasal discharge is usually noninfectious in origin
and caused by allergy or vasomotor rhinitis
• An uncomplicated URI is characterized by sore or scratchy
throat, laryngitis, sneezing, rhinorrhea, congestion,
malaise, nonproductive cough, and temperature > 38°C
• More severe URI or LRI may include severe
nasopharyngitis, purulent sputum, high fever, deep
cough, and associated auscultatory findings of wheezes
or rales
• It is generally agreed that chronic nasal discharge poses
no significant anesthesia risk
• In contrast, children with severe URI or LRI almost
always have their elective surgery postponed
• Probably most anesthesiologists will proceed to
surgery with a child with a resolving uncomplicated
URI, unless the child has a history of asthma or other
significant pulmonary disease
THANK YOU