Preoperative assessment

for elective surgery

PRESENTED BY: DR. KHALED ALHARAZIN
Outlines 

1. Introduction
2. Goals and Objectives
3. History and examination
4. Airway assessment
5. Medical comorbidities
6. Risk assessment
7. Preoperative testing
8. Preoperative drug management
1. Introduction

► Preoperative assessment of patients undergoing elective surgery is vital to ensure patients

have underlying comorbidities identified.
► Anesthetic pre-assessment is usually initiated at the pre-assessment clinic.
► A thorough assessment should include a careful history and examination as well as
assessment of both the airway and functional capacity.
► A well performed evaluation brings up an accurate estimation to patient's general condition.
► Preoperative assessment predicts possible complications and gives a plan of anesthesia.
2. Goals and objectives

► Identify any pathology requiring prior management.

► Optimize pre-existing medical conditions.
► Ensure appropriate pe-op investigations are arranged.
► A time for other specialty consultation.
► Reduces day-of-surgery cancellation.
► Categorizes high risk patients to the appropriate anaesthestic team and plan.
► A stress reliefer appointment.
► Lifestyle modification advice (smoking cessation, weight loss).
3.1 History 

► Identifies medical comorbidities

► Drug history including currently used, what to stop and what to stay on
► Previous anesthetic history
► Allergy
► Family history should include prior anesthetic experience or complications
that might give a clue to inherited or genetic predisposition
► Risk of aspiration assessment
3.2 Examination 

► General physical examination reveals abnormalities and guides further evaluation

► Cardiovascular and respiratory examination
► Neurological examination including mental status, cognition and any neurologic disease
► Extremities for possible sites of iv access or nerve block should be checked for site
infection or deformity
► Back should be inspected for any deformity (kyphosis, scoliosis, infection) if regional
anesthesia to be planned
4. Airway assessment

► A core component of preoperative assessment

► Predicts patients with possible difficult BMV or endotracheal intubation

► Plan a strategy for airway management

► Previous anesthetic documentation regarding airway management can be

helpful
4.1 Predictors for difficult BMV

► Obesity: BMI > 30

► Neck circumference > 60 cm
► Beard (difficulty in obtaining a good seal)
► Edentulous (lacking teeth) patients
► Snoring
► Anatomical facial deformity
► Radiation
4.2 Predictors for difficult laryngoscopy

1. Mouth opening:

❖ 4-6 cm of inter-incisor gap

❖ Vertical fitting of patient's index, middle and ring fingers
❖ Ability to open mouth less than 3 cm is regarded a sign of potential difficulty
Normal mouth opening
► There are medical conditions associated with
limited mouth opening:

Arthritis of jaw bones, Scleroderma, SLE,

Inflammation, TMJ abnormalities
Mallampati classification

2. Mallampati scoring system:

❖ Assesses the view of the oropharynx

❖ Performed while sitting, head in neutral position, mouth opened
maximally and tongue protruded without phonation
Mallampati classification

► Provides an estimate of space

available for oral intubation by
direct laryngoscopy.

► In general, Mallampati class I or

II predicts easy laryngoscopy,
class III predicts difficulty, and
class IV predicts extreme
difficulty.
4.2 Predictors for difficult laryngoscopy

3. Jaw protrusion (ability to prognath):

❖ Inability to protrude the lower jaw is associated with poor view at

laryngoscopy
Jaw protrusion

► Class1: able to bring lower jaw over

upper jaw (bite upper lip)

► Class2: upper and lower jaws are

aligned

► Class3: inability to bring lower jaw

ahead of upper jaw (poor view)
Micrognathia

► Pierre Robin syndrome

► Beckwith-Wiedemann
syndrome

► Treacher Collins syndrome

4.2 Predictors for difficult laryngoscopy

4. Thyromental distance: (patil's test)

❖ From the upper border of thyroid cartilage to the tip of jaw with neck
fully extended.
❖ <6 cm is associated with difficult view at laryngoscopy.
❖ Measured with 3 finger breadths.
4.2 Predictors for difficult laryngoscopy

5. Neck movement:

❖ Sniffing position is the optimal position of direct laryngoscopy.

❖ Cervical flexion (head flexion) and neck extension at the
atlantoaxial joint.
NOTE: History of radiation, surgery, burn, arthritis, RA, DM can affect neck mobility.
Wilson scoring system
► Total score <5 : Easy laryngoscopy
► 6-7 : Moderate difficulty
► >7 : Extreme difficulty
5. Medical comorbidities

5.1 Cardiovascular disease

5.1.1 Hypertension

► Hypertensive patients are at increased risk of an exaggerated fall in systolic blood

pressure on induction of anaesthesia

► They have an exaggerated sympathetic response to stresses such as laryngoscopy

and pain

► This can potentially precipitate myocardial ischaemia and cerebrovascular

accidents

► Other coexisting diseases including coronary artery disease, cerebrovascular

disease and diabetes mellitus should be sought
Goals of pre-op assessment in HTN

► Identify secondary causes of hypertension ( primary renal, pheochromocytoma,

OSA, hyperthyroidism, Cushing)

► Detect evidence of end organ damage

► The presence of end-organ damage or co-existing disease may significantly

elevate the patient’s risk and may need to be investigated further

► Pre op cardiovascular optimization return vascularity toward normal and help

reducing risk outcomes
► Long term antihypertensive medications should continue until the
day of surgery.

► ACEIs/ARBs are advised to stopped 24 hours before surgery due

to intraoperative hypotension.
5.1.2 Coronary Artery Disease

► CAD may range from stable angina to previous myocardial infarction with
evidence of heart failure.

► Well-controlled, stable angina need not delay elective surgery.

► Unstable angina which occurs at rest, or angina which is increasing in frequency

or severity, may require further investigation prior to elective surgery, including
review by a cardiologist to optimize medical treatment.
► Risks:

1. MI.
2. Post operative myocardial damage.
3. Increased risk of 30 day post operative mortality.
► Goals:

1. Detect undiagnosed significant IHD.

2. Determine severity of existing IHD, functional limitation, therapy and previous
investigations.
3. Determine if preoperative consultation is needed.
Functional status

► Metabolic equivalents METs:

❖ Functional status can be used as a predictor of perioperative events

❖ Metabolic equivalents allow estimation of an individual’s functional

capacity

❖ One metabolic equivalent is the resting oxygen consumption of a

40-year-old 70 kg man (3.5 mlkg/min)
► In general, perioperative cardiac risks
are increased in patients with a
METS < 4
2014 AHA/ACC stepwise approach in CAD
patients for elective non-cardiac surgery
 5.1.3 Percutaneous coronary intervention

► The AHA/ACC guidelines set out specific recommendations regarding then

timing of elective surgery in patients who have had recent percutaneous
coronary intervention.

► The taskforce recommends that elective non-cardiac surgery should be:

❖ Delayed 14 days after balloon angioplasty
❖ Delayed 30 days after bare metal stent (BMS) insertion
❖ Optimally delayed 1 year after drug-eluting stent (DES) insertion.
5.1.4 Valvular Heart Disease

► Valvular heart lesions can significantly increase cardiac risk.

► Patients with suspected moderate or severe degrees of valvular stenosis

or regurgitation should have a preoperative echocardiogram if:

❖ There has not been one for a year

❖ There has been a significant change in clinical status or physical
examination since the previous echocardiogram.
5.1.5 Implanted Cardiac Devices

► They are mostly used in the presence of abnormal cardiac conduction

system

► ICDs will need to be deactivated for surgery and communication with

the cardiology department should begin early in the pre-assessment
process.
5.1.6 Stroke

► Patients with cerebrovascular disease are at risk of further events perioperatively and
in particular may be intolerant of swings in blood pressure.

► A detailed history and examination should be done to evaluate any existing

neurological impairment.

► There is little evidence available to guide decisions regarding optimal timing of

elective surgery following a stroke.

► Risks appear to be most elevated in the first 3 months, although not surprisingly risk
remains elevated beyond this period and as with CAD, a balance of risks should be
made.
► Preoperative assessment in stroke patients should include:

❖ Timing, etiology, treatments of previous strokes or TIAs.

❖ Brief neurologic exam to detect deficits.
❖ Auscultation for carotid bruit, auscultation for valve lesion.
❖ Review drugs, antiplatelet, vit k antagonists.
5. Medical comorbidities

  

5.2 Pulmonary disease

5.2.1 Smoking

► Increased carboxyhemoglobin levels.

► Decrease ciliary function.
► Increase sputum production.
► Nicotine adverse effects on cardiovascular system.

► Preoperative advices:
❖ 2 days cessation can decreases nicotinic effect, improve mucus clearance
and decrease carboxyhemoglobin levels
❖ 4-8 weeks of cessation are believed to be needed for postoperative
complication reduction
5.2.2 Asthma

► Obtain information about irritating factors, severity and current disease

status.

► Frequents use of bronchodilators, recurrent hospitalization and requirements

for systemic steroids are all indicators of severe disease.

► Those who received more than a (burst and taper) of steroids in the previous
6 months should be considered for stress dose perioperatively.
5.2.3 OSA

► A major cause of upper airway obstruction and a leading cause to chronic

pulmonary hypertension and right sided heart failure

► Physical characteristics associated with increased risk:

❖ Obesity
❖ Increase neck circumference
❖ Severe tonsillar hypertrophy
❖ Nasal obstruction
► ASK the following in the suspected OSA patients:

✔ Does the patient snore loudly?

✔ Is there any pause during sleep?
✔ Any frequents arousals or awakening with chocking sensation?
✔ Daytime somnolence?
✔ If a child, sleep in unusual positions, new onset enuresis?
5.2.4 COPD

► Severity classified according to the percentage of predicted forced expiratory

volume in 1 second:

❖ FEV1 >80% mild

❖ FEV1 50-79% moderate
❖ FEV1 30-49% severe
❖ FEV1 <30% very severe

► COPD patients are vulnerable to have pulmonary hypertension and cor pulmonale
► A full history in COPD patients is essential:

✔ How many stairs can you climb before catching a breath?

✔ Are you breathless when washing yourself?
✔ Frequency of exacerbations.
✔ Hospital admission history.
✔ Previous need for invasive or non invasive ventilation.
✔ Requirements for steroids.
5.2.5 Respiratory Tract Infection

► Patients presenting on the day of surgery with symptoms and signs of a lower
respiratory tract infection should be treated appropriately and postponed to such
time that they are symptom free.

► Viral upper respiratory tract infection can cause bronchial reactivity which may
persist for 3-4 weeks.

► Unless surgery is urgent, such patients should be postponed for 4 weeks to

minimize the risk of postoperative respiratory infection
5. Medical comorbidities

5.3 Endocrine disease

5.3.1 Diabetes Mellitus

► Diabetics are at increased risk of medical and surgical complications

including:

❖ Cardiac and renal disease

❖ Cerebrovascular disease
❖ Microvascular disease (retinopathy, nephropathy, neuropathy)
❖ Autonomic neuropathy, gastroparesis, risk of aspiration
❖ Stiff joint syndrome
► Question about type, dose, time and frequency and manifestation of hypoglycemic
attacks
► Target range of hemoglobin A1c according to american Diabetic Association is <7.5 %
for type 1 and <7 % for type 2
► Levels >8 % or hypoglycemia unawareness attacks need preoperative endocrinologist
referral
► Prayer's sign: diabetics who are unable to oppose their hands, should be suspected for
also having changes in other joints impacting airway manipulation
► Diabetic patients should be first on the list and prompt return to normal oral intake
(minimize starvation time)
► Consider mutimodal analgesia, antiemetics
                        Prayer's sign
► Oral hypoglycemic agents are held on the day of surgery to avoid reactive
hypoglycemia.

► Insulin is usually continued through the evening before surgery.

► Type 1 diabetics should be continued on basal insulin administration even

during preoperative fasting t prevent ketoacidosis.
5.3.2 Thyroid and Parathyroid Disease

► A hypo or a hyperthyroidism should be evaluated for possible

complications

► A large thyroid mass may distort the upper airway producing inspiratory
stridor or wheezing, a CXR can show if there is tracheal deviation

► Hyperparathyroid patients often have hypercalcemia, pre-op serum

calcium level is warranted
5. Medical comorbidities

5.4 Renal disease

► Renal disease has important implication for fluid and electrolyte
management and drug metabolism.
► Those on dialysis should be questioned on timing of sessions to
determine volume status.
► Assess patient's electrolytes prior to surgery.
► Discussion with the nephrologist to make sure patients reach their
surgery in euvolemic status.
► Renal failure patients tend to be anemic.
Anemia

► Anemia limits tissue oxygenation and is poorly tolerated in patients with

coronary artery disease or ventricular failure.

► If anemia is identified at the PAC then attempts to categorize iron deficiency

anemia, anemia of chronic disease or a primary hematological cause should be
made.

► If an unexpected iron deficiency is identified this should be appropriately

investigated to exclude malignancy.

► Treatment and prior management should be guided depending on etiology.

Rheumatoid arthritis

► Rheumatoid arthritis is a multisystem inflammatory disorder that has many

implications for anesthesia.

► Patients may have significant cervical spine or temporomandibular joint

involvement which may predispose to airway difficulty and the need for an awake
intubation

► In severe disease, patients may have pericardial effusions, pulmonary fibrosis and
renal impairment.

► Often patients suffer from chronic pain and are on an array of medications which
should ideally be continued in the perioperative period.
American Society of Anesthesiologists
physical status classification
6. Risk assessment

► Medical comorbidities and type of surgery are important indicators of operative

and postoperative outcomes.
► Risk should be assessed and documented for all patients.
► Discussion with the patient the possibility of further postoperative care i.e.
Intensive care unit admission
► The type of surgery should be taken into consideration during the pre-assessment
process
► Higher perioperative risk is associated with major and major complex surgery
NICE classification of type of surgery

Grade  Example 

Grade 1(minor) Excision of skin lesion, drainage of breast

abscess

Grade 2 (intermediate) Knee arthroscopy, primary inguinal hernia

repair, excision varicose veins

Grade 3 (major) Total abdominal hysterectomy, endoscopic

resection of prostate, lumbar discectomy,
thyroidectomy

Grade 4 (major complex) Thoracic surgery, colonic resection, radical

neck dissection, elective abdominal aortic
aneurysm repair
Cardiac risk assessment

► The most widely used tool for prediction of perioperative cardiac complications is the
Revised Cardiac Risk Index.
► The RCRI uses six preoperative clinical variables that are equally weighted to produce
an estimated risk of cardiac complications:
❖ High risk type of surgery (supra-inguinal vascular, intraperitoneal or intrathoracic
surgery).
❖ History of ischemic heart disease.
❖ History of congestive heart failure.
❖ History of cerebrovascular disease (stroke or TIA).
❖ Insulin therapy for diabetes mellitus.
❖ Preoperative serum creatinine >2.0 mg/dl.
Predicted risk of cardiac complications
using the Revised Cardiac Risk Index (RCRI)

Number of risk factors present Rate of cardiac complications (%)

0 0.5

1 1

2 5

3 10

4 15
7. Preoperative testing

► Routine preoperative testing should be avoided.

► Tests and investigations should follow local guidelines to decrease patient

alarm, false positive results, risks, and delay of surgery.

► The predictive value of abnormal tests is low in healthy patients with a low
prevalence of disease.
7.1 Preoperative cardiovascular
investigations

► Electrocardiogram:
According to 2014 ACC/AHA guidelines on preoperative evaluation, ECG testing
falls in the following:
❖ Anyone with history of cardiovascular disease such as coronary artery disease,
arrhythmia, peripheral arterial disease, cerebrovascular disease or structural heart
disease.
❖ Not required in patients with no history of coronary artery disease undergoing low
risk surgery.
❖ Consider in asymptomatic patients with no history of coronary artery disease if
undergoing intermediate or high-risk surgery.
► Echocardiogram:

❖ To assess left ventricular function if patients are known to have LV dysfunction and
no echo has been performed within a year.
❖ In patients with known heart failure with increasing dyspnea or a change in their
clinical status.
❖ Reasonable to perform preoperative evaluation of LV function in patients with
dyspnea of unknown cause.
❖ In patients with clinically suspected moderate or greater degrees of valvular stenosis
or regurgitation if there has been either no echo within 1 year or a significant change
in clinical status or physical examination since last echo.
► Exercise tolerance test:

❖ Consider in patients with increased risk and unknown functional capacity

if it will change management.

❖ Consider in patients with increased risk and poor/unknown functional

capacity along with cardiac imaging to assess for myocardial ischemia.

❖ Not indicated for patients with increased risk if they have moderate to
excellent functional capacity (>4-10 METs)
7.2 Other lab testing

► CBC:
❖ A baseline CBC is suggested for all patients 65 years of age or older
❖ When planning neuraxial anesthesia, it is reasonable to measure PLT count

► Renal function test:

❖ Appropriate to obtain serum creatinin in patients over 50 scheduled for intermediate or high
risk surgeries
❖ Base line renal function should be obtained in CKD patients
❖ Renal impairment is risk factor for post operative complications, drug dosing to be adjusted
► Electrolytes:
❖ Not ordered routinely unless there is what suggest abnormality.
❖ Predictors of abnormality can be obtained from history (drugs altering.
electrolytes, patients with CKD).

► RBS:
❖ Should be obtained in diabetics.
❖ RBS abnormalities increase with age.
❖ Insulin treated diabetics are at increased risk of postoperative complications.
► Liver function test:
❖ Ordered in liver disease patients
❖ Suspect liver disease from history and examination (jaundice, ascites, itching,
abdominal pain)

► Urine analysis:
❖ Not ordered routinely
❖ If done, to detect UTI, a risk for bacteremia and possible postoperative complications
► Tests for hemostasis:

❖ Should be done in suspected patients from history and examination.

❖ Petechiae, telangiectasia, spider angioedema should alert toward testing liver function,
PLT, PT, PTT.
❖ Patients with family history of bleeding disorders should be investigated.
❖ Hemophilia carriers may have normal aPTT but reducing factor levels.

► COVID-19:
❖ Guidelines suggest screening for exposure or symptoms of coronavirus disease.
❖ Testing is advised in areas of high prevalence.
7.3 Pulmonary function testing

► Not indicated for healthy patients.

► Recommended in unexplained dyspneic patients.
► Recommended in uncontrolled pulmonary disorders patients with poor
functional capacity.
► CXR:

❖ ACP recommends cxr in patients with cardiopulmonary disease and those >50
years old presenting for upper abdominal or thoracic surgeries.
❖ AHA recommends PA, Lateral chest imaging for patients with severe obesity
(undiagnosed HF, chamber enlargement, abnormal pulmonary vasculature
suggestive of pulmonary hypertension).
❖ Not done routinely in smokers unless history suggest pulmonary compromise or
active infection.
7.4 Fasting

Ingested material Minimum fasting hours

Clear liquid (water, clear tea, black 2

coffee, fruit juice without pulp)

Breast milk 4

Formula milk, non huma milk, light meal 6

Regular or heavy meal 8

► Prolonged fasting should be avoided as this is associated with dehydration,
increased postoperative nausea and vomiting, electrolyte imbalance and
patient distress.

► Optimal fasting hours decreases volume and acidity of stomach contents and
reduce aspiration and regurgitation risk.
8. Preoperative drug management

Continue on the day of surgery drugs

1. Antihypertensive medications 7. Reflux medication

2. Cardiac medications (e.g., β-blockers,
digoxin)
3. Antidepressants, anxiolytics and other
psychiatric medications
4. Thyroid medications
5. Oral contraceptive pills
6. Eye drops
8. Opioid medication
9. Anticonvulsant medications
10. Asthma medications
11. Corticosteroids (oral and inhaled)
12. statin
► Insulin:

❖ For all patients, discontinue all short-acting (e.g., regular) insulin on the day of surgery
(unless insulin is administered by continuous pump).

❖ Patients with type 2 diabetes should take none, or up to one half of their dose of
long-acting or combination (e.g., 70/30 preparations) insulin, on the day of surgery.

❖ Patients with type 1 diabetes should take a small amount (usually one third) of their
usual morning long-acting insulin dose on the day of surgery.

❖ Patients with an insulin pump should continue their basal rate only.
► Non-insulin antidiabetic medications:

❖ Discontinue on the day of surgery (exception: SGLT2 inhibitors should be

discontinued 24 hours before elective surgery)
► P2Y12 inhibitors (e.g., clopidogrel, ticagrelor, prasugrel, ticlopidine) 
Patients having cataract surgery with topical or general anesthesia do not need to stop
taking thienopyridines.

If to be stopped, the time interval for discontinuing these medications before surgery is:

❖ 5–7 days for clopidogrel

❖ 5–7 days for ticagrelor
❖ 10 days for ticlopidine
► Do not discontinue P2Y12 inhibitors in patients who have drug-eluting stents
until they have completed 6 months of dual antiplatelet therapy, unless risks
of discontinuation have been discussed.

► The same applies to patients with bare metal stents until they have completed 1
month of dual antiplatelet therapy.
► Aspirin:

❖ Traditionally, antiplatelet agents were stopped prior to elective surgery due to the
perceived risk of bleeding.

❖ There is now evidence that stopping aspirin leads to a rebound pro-thrombotic

state, increasing the risk of cardiovascular complications.

❖ Continue aspirin in patients with prior percutaneous coronary intervention,

high-grade IHD, and significant CVD. Otherwise, discontinue aspirin 3 days
before surgery.
► Anticoagulation: 

❖ In patients receiving oral anticoagulation, bleeding risk must be balanced against

the benefit of continuing anticoagulant therapy.

❖ Patients with prosthetic valves or recurrent thrombo-embolic events who are

taking warfarin therapy require bridging therapy with either low molecular
weight heparin or unfractionated heparin.

❖ Rivaroxaban should be withheld for up to 48 hours.

► NSAIDS:
Should be stopped 48 hours before surgery

► Topical medication (creams, ointments)

Discontinue in the day of surgery
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