Pre- Anaesthetic Check Up:

It means the assessment of the patient prior to any surgery to see whether he/she is fit for anaesthesia.

Importance:

a) To do a safe anaesthesia-induction, maintenance & recovery.

b) To prevent Pre-Operative complications.
c) To prevent post- operative hazards.

Objectives of preoperative assessment/ check up:

1) To understand the general principles of preoperative preparation.

2) In high risk patients how preparation may lower the risk.
3) To understand the principles of preparation for specific types of operation.
4) To appreciate the value of protocols and routines and the importance of adhering to them-even
in emergency situation.

Objectives of Pre-operative preparation:

1) Gather and record concisely all relevant information.

2) Devise a plan to minimize risk and maximize benefit for the patient.
3) Consider possible adverse events and plan how to deal with them.
4) Communicate to ensure everyone (including the patient) understands the surgical plan.

Preparation for general anaesthesia:

1) Proper Assessment
a) History about allergy, bronchial asthma, chest pain & cough.
b) Physical examination: Height, weight, pulse, BP, heart, lungs, teeth, tongue.
2) Medical check – list:
a) Cardiovascular- hypertension, angina, arrhythmias, failure.
b) Respiratory- infection, asthma.
c) Gastrointestinal- regurgitation, bowel obstruction, jaundice.
d) Metabolic- porphyria, hyperpyrexia, pheochromocytoma, steroids, diabetes.
e) Coagulation- hereditary and acquired.
f) Neurological- consciousness level, cervical instability.
3) Investigations:
a) Blood:
i) Blood for TC, DC, Hb%, ESR.
ii) Blood sugar: Fasting / Random / Post-prandial.
iii) Blood urea.
iv) Serum creatinine.
b) Urine for routine examination (R/E) for protein, sugar, casts and pus cell, Culture sensitivity is
required if there is features of UTI [ pus cells more then 5/HPF (high power field)].
c) Chest X-ray P/A view.
 d) ECG (if age 40 years or more).
4) Starvation before surgery:

Four hours abstinence from food is standard practice, and should be used even with elective
regional anaesthesia and also with light intravenous anaesthesia.

5) Consent for surgery and anaesthesia:

Written informed consent should be taken by the surgical team before any sedation is given.
6) Preoperative drugs and treatment:
a) Sedation and analgesia.
b) The anticholinergic agent (e.g. atropine) is used to reduce respiratory and oral secretions.
c) Prophylactic antibiotics.
d) H2 blocker or portion pump inhibitor to reduce gastric secretion.

Anaesthetic premedication: administration of drugs before & during operation, in addition to GA, to
make the anaesthesia safe and agreeable to the patient is called anaesthetic premedication.

Pre- Anaesthetic medication:

1) For analgesia Opioid analgesics:

✓ Morphine
✓ Pethidine
✓ Fentanyl

2) To reduce anxiety BDZ compounds: Diazepam, Midazolam

3) To reduce bronchial & salivary secretion • Atropine

• Hyoscine
• Glycopyrronium

4) To reduce gastric acidity ▪ Omeprazole

▪ Pantoprazole
▪ Ranitidine

5) To prevent infection (in general & pelvic ✓ 2nd / 3rd / 4th generation cephalosporin:
surgery) Cefoxitin, Ceftriaxone, Cefepime
✓ Fluroquinolones: Ciprofloxacin,
Levofloxacin, Lomefloxacin

6) To prevent vomiting ▪ Domperidone

▪ Metoclopramide
7) For emptying intestinal content (for  Laxatives
general & gynecological operation)
For more Curiosity:

Common investigations for surgical patients:

Test Indication

Haematology ➢ Routine for Many (check protocol)

➢ Needed to exclude anemia
➢ Include platelet count if bruising is present

Creatinine and Electrolytes ➢ Routine for Many (check protocol)

➢ Needed for all patients who are dehydrated or may have renal
problems.

Liver function tests ➢ Routine For Many (check protocol)

➢ Check protein and albumin if patient is malnourished.
➢ Needed in all patient with compromised liver function.

Clotting screen ➢ Required in any patient who is bruising or bleeding or is

anticoagulated.
➢ Needed in all patients with compromised liver function.

Electrocardiography (ECG) ➢ Routine For Many (check protocol)

➢ Needed in all patients with hypertension or a history of cardiac
problem.

Chest radiography ➢ Routine For Many (check protocol)

➢ Needed in all patients with a history of cardiac or pulmonary
problems.

Urinalysis ➢ Routine For Many (check protocol)

➢ Needed in all patients with renal tract problems.

Pregnancy test ➢ Needed in all cases in which patients has any chance of being
pregnant.
➢ Consent to test must be obtained.

HIV ➢ Needed in all high-risk cases.

➢ Patient must give consent and receive counseling.
Suggested prophylactic regimens for operations at risk:

Type of surgery Organisms encountered Prophylactic regimen

Vascular Staph, epidermidis, aureus, 3 doses of flucloxacillin +-
Aerobic Gram-negative bacilli gentamicin, vancomycin or
rifampicin.

Orthopaedic Staph. Epidermidis/ aureus 1-3 doses of wide-spectrum

cephalosporin (with antystaphy
locaccal action), Gentamicin

Oesophagogastric Enterobacteriaceae, 1-3 doses of second-generation

Enterococci cephalosporin and metronidazole in
severe contamination.

Biliary Enterobacteriaceae (mainly E.coli). 1 dose of second-generation

Small bowel
The appendix / colorectal
Enterococci (including strep, faecalis)
Enterobacteriaceae
Anaerobes (mainly Bacteroides)
Enterobacteriaceae, Anaerobes
cephalosporin
1-3 doses of second- generation
cephalosporin + metronidazole
3 doses of second- generation
cephalosporin (alternatively
gentamicin) with metronidazole

Preparation of a diabetic patient for surgery:

The patients are at high risk of complications. A careful preoperative assessment of their cardiovascular,
peripheral vascular and neurological status should always be made.

Possible preoperative risk-reduction strategies may include (but are not limited to) introducing lipid-
lowering medication, improving diabetic control and treating significant vascular stenosis.

1) Preparation for minor surgery: Minor surgery in the non-insulin dependent diabetic can be
managed by simply omitting their morning dose of medication, listing them for early surgery
and restarting treatment when they start eating postoperatively.
2) Preparation for major surgery: For more significant surgery, and in the insulin dependent
diabetic: -
• An intravenous insulin infusion will be required. This should be started when the
patient first omits a meal and continued until they have recovered from the surgery.
• The plasma potassium level must be closely monitored.
• There is a risk of life-threatening lactic acidosis in patient taking metformin who are to
have contrast angiography. This drug should be discontinued 24 hours before the test
and restarted 24-48 hours afterwards.