PREOPERATIVE

EVALUATION

Vaishali Syal
Moderator - Prof. J. R. Thakur
Introduction

Preoperative evaluation of a patient is

necessary to ensure that patient is
asymptomatic from the anaesthetic risk
point of view before surgery by
physiological and psychological
preparation.
 What is Anestheia?

Triad of
 Amnesia (reversible loss of consciouness)

 Analgesia (pain relief)

 Areflexia (muscle relaxation)

Purpose of effective Pre op
Evaluation
 to identify those few patients whose outcomes
likely will be improved by implementation of a
specific medical treatment (which in rare circumstances
may require that the planned surgery be rescheduled).
 to identify patients whose condition is so poor
that the proposed surgery might only hasten
death without improving the quality of life.
 Identify patients with specific
characteristics that likely will influence the
proposed anesthetic plan
 to provide the patient with an estimate of
anesthetic risk.
 an opportunity for the anesthesiologist to
describe the proposed anesthetic plan in
the context of the overall surgical and
postoperative plan
 Provide the patient with psychological
support
 obtain informed consent for the proposed
anesthetic plan from the surgical patient.
 Effective preoperative
evaluation include :-
 history and physical examination
 a complete account of all medications taken by
the patient in the recent past
 all pertinent drug and contact allergies
 responses and reactions to previous
anesthetics.
 any indicated diagnostic tests, laboratory
investigations, imaging procedures, or
consultations from other physicians.
Source- Morgan and Mikhail Clinical Anesthesiology 5th edition
 Elements of Pre Op History

Patients presenting for elective surgery and anesthesia

typically require a focused preoperative medical history
emphasizing :-

 cardiac and pulmonary function

 kidney disease, endocrine and metabolic diseases
 musculoskeletal and anatomic issues relevant to
airway management and regional anesthesia, and
 history of responses and reactions to previous
anesthetics/drugs.

 family/personal history

 Any coexisting illness

 Exercise tolerance
 Elements of Physical Pre op
Evaluation
 measurement of vital signs (blood pressure,
heart rate, respiratory rate, and temperature)
 examination of the airway, heart, lungs,

and musculoskeletal system

 standard techniques of inspection,
auscultation, palpitation are used.
 Breath holding time should be assessed in

every patient(normal value >25 seconds ; 15-

20seconds is considered borderline).
 Proper examination of patient’s airway
 Inspection of loose or chipped teeth,
caps, bridges, or dentures.
 Micrognathia (a short distance between
the chin and the hyoid bone), prominent
upper incisors, a large tongue, limited
range of motion of the temporo
mandibular joint or cervical spine, or a
short or thick neck
Investigations

 Routine investigations vary from hospital

to hospital, state to state and country to
country.
 ECG : should be performed for every patient
aged between 40-50 years.
 RFT : recommended for every patient aged
> 40 years.
 Chest X-ray : done as a routine practice
 Blood glucose measurement for diabetic
patient
 Urine analysis
 Coagulation profile for patients with suspected
coagulopathy.
 By convention, physicians in many countries use the American
Society of Anesthesiologists’ (ASA) classification to define relative
risk prior to conscious sedation and surgical anesthesia

Source- Morgan and Mikhail Clinical Anesthesiology 5th edition

 Cardiovascular issues

 The core goals of preoperative cardiac

assessment are to :
o determine the status of the patient's cardiac conditions
o to provide an estimate of risk
o to determine if further testing is warranted
o and to determine if interventions are warranted to
reduce perioperative cardiac risk.
 In general, the indications for cardiovascular
investigations are the same in surgical
patients as in any other patient.
Pulmonary issues

Cases where there is markedly increased risk of

pulmonary complications :

 ASA Class 3 and Class 4 patients as compared

to Class 1 patients.
 Cigarette smoking
 Longer surgeries(>4 h)
 Certain types of surgery(abdominal, thoracic,
aortic aneurysm, head and neck, and emergency
surgery)
 General Anesthesia(compared with cases in
which GA was not used)
Efforts required for prevention of pulmonary
complications

 focus on cessation of cigarette smoking

prior to surgery and on lung expansion
techniques (eg, incentive spirometry) after
surgery in patients at risk.
 Patients with asthma, have a greater risk
for bronchospasm during airway
manipulation.
 Appropriate use of analgesia and
monitoring are key strategies for avoiding
postoperative respiratory depression in
patients with obstructive sleep apnea.
 Coagulation issues

 to manage patients who are taking warfarin on

a long-term basis;
 to safely provide regional anesthesia to patients
who either are receiving long-term
anticoagulation therapy or who will receive
anticoagulation perioperatively.
 patients deemed at high risk for thrombosis
(eg, those with certain mechanical heart valve
implants or with atrial fibrillation and a prior
thromboembolic stroke), warfarin should be
replaced by intravenous heparin or, more
commonly, by intramuscular heparinoids to
minimize the risk.
Gastro intestinal issues

 the risk of aspiration is increased in

certain groups of patients :-
o pregnant women in the second and third
trimesters,
o those whose stomachs have not emptied after
a recent meal,
o and those with serious gastroesophageal
reflux disease (GERD).
Treatment of GERD :
 to treat patients with consistent symptoms
(multiple times per week) with medications
(eg, nonparticulate antacids such as sodium
citrate) and techniques (eg, tracheal
intubation rather than laryngeal mask airway)
as if they were at increased risk for aspiration.
Fasting
recommendations
Ingested material Minimum fasting
period(in hrs)
 Clear liquids 2
 Breast milk 4
 Infant formula 6
 Non human milk 6
 Light meal (toast & 6
clear liquids)
Airway assessment
Predictors of difficult intubation
 Mallampati classification
 ULBT
 Measurements (IID, TMD, SMD)
 Movement of the neck
 Deformities
 Thyromantal distance

Upright, neck extension, mouth closed,

distance < 6.5 cm is difficult intubation
 Sternomantal distance

Extended head & neck, mouth closed,

distance < 12.5 cm is a difficult intubation
Movement of neck
Craniofacial deformities
Why would this patient’s
airway be difficult to manage?
Why would this patient’s
airway be difficult to manage?
Conclusion
Preoperative evaluation is scenario which
utilizes vast scales anaesthesiologists
knowledge in a limited span to ensure

 Increased quality of preoperative care

 Reduced mortality and morbidity of surgery
 Reduced cost of preoperative care
 Reduced anxiety
Thank you