PREOPERATIVE

ASSESSMENT,
PREMEDICATION Dr. MUSTAFA KHRISHI
,& Department of Anesthesia

PERIOPERATIVE
Darwish Nazzal Hospital
Palestine

DOCUMENTATIO
N
PREOPERATIVE EVALUATION
Cornerstones are medical history and physical examination including complete up-to-date
listing  of :-
 All medication taken by the patient in recent past
 All patient allergies
 Responses and reactions to previous anesthetic experience
 Diagnostic tests, imaging procedures
 Consultation from other physicians
PURPOSE OF PREOPERATIVE
EVALUATION
Preoperative evaluation serves multiple purposes 
1. Identification of patients whose outcomes will be improved by implementation of specific
medical treatments e.g. a 60 year old with hip arthroplasty plus CAD
2. Identification of patients whose condition is so poor that it will hasten death without
improving the quality of life e.g.  severe chronic lung disease , ESRD, liver failure, CHF
3. PRE OP evaluation also uncovers findings that will change anesthetic plan e.g. difficult
intubation, family history of malignant hyperthermia, infection near regional anesthesia
site 
4. Estimation of anesthetic risk
5. Provides patient with psychological support and obtain informed consent for the proposed
anesthetic plan from surgical patient  
Many physicians use ASA (American
Society of Anesthesiologists) classification
to define relative risk prior to anesthetic
management
Advantages are :
 Time tested 
 Simple
 Reproducible
 Strongly associated with perioperative risk
& outcomes
ELEMENTS OF PREOPERATIVE
HISTORY 
 Medical history including
• exercise tolerance
• nutritional and functional status
• Cardiac, pulmonary, kidney & liver function
• electrolytes or metabolism
• anatomical issue relevant to airway management or regional anesthesia 
 How the patient responds to and recovered from previous anesthetic
CARDIOVASCULAR
COMPONENT
The focus of preoperative cardiac assessment 
 Baseline Heart Rate, Blood Pressure
 Any past or current History of Cardiac or Vascular issues i.e. MI, CAD, Angina, Vasculitis
 Whether the patient would benefit from further cardiac evaluation or intervention prior to
schedule surgery->( same approach is not appropriate for all patients)
PULMONARY COMPONENT
 Perioperative pulmonary complications  notably postoperative respiratory
depression ,respiratory failure are associated with obesity and obstructive sleep apnea
 According to the guideline by American college of physicians we need to identify patients of
 60 yrs. age or older with COPD
 reduced exercise tolerance
 Patients with functional dependance i.e. Asthmatics
 Patients with heart failure as potentially requiring pre operative and post operative interventions to
avoid respiratory complications
RISK OF POST OPERATIVE
RESPIRATORY COMPLICATIONS
 Associated with these factors
 ASA status 3 and 4
 Cigarette smoking 
 Surgeries lasting more than 4 hours
 Certain types of surgeries (abdominal, thoracic, aortic aneurysm, head and neck surgeries and
emergency surgeries)
PREVENTION OF PULMONARY PATIENTS AT
RISK

 Cessation of smoking several weeks before surgery

 Lung expansion techniques after surgery i.e. Chest physiotherapy, Incentive Spirometry
 Patient with asthma receiving sub-optimal medical management have greater risk for
bronchospasm during airway manipulation 
 Appropriate use of analgesia and monitoring are key strategies for avoiding postoperative
respiratory depression in patents with obstructive sleep apnea 
ENDOCRINE AND METABOLIC
COMPONENT
 Tight control of blood glucose -->within normal target range-->was shown in the diabetes control and
complication trial to improve outcome in ambulator patient with type 1 DM
 Other more recent trials conducted in critically ill pt. have shown that blood glucose should not be so
tightly controlled
 Usually we measure FBG on the morning of elective surgery

 Long term blood glucose control can be assessed by measurement of HBA1c if abnormally elevated -->
referral to diabetology service for management
 Elective surgery should be delayed in patient with marked hyperglycemia otherwise in well managed
patient with type 1 DM ->delay to allow insulin infusion to bring the blood glucose conc closer to normal
range before surgery
COAGULATION COMPONENT
 3 important issues must be addressed:
 How to manage pt. who are taking warfarin and other long acting anti coagulant on long term basis
 How to manage pt. with CAD taking clopidogrel
 Whether one can safely provide neuraxial anesthesia to patient who are receiving long term
anticoagulation therapy 
 They should stop anti coagulation in advance of surgery to avoid excessive blood loss
 Key issue ->how far in advance the drug should be discontinued and whether pt. will require
bridging therapy with short acting agent  
COAGULATION COMPONENT
 In pt. with high risk for thrombosis ->chronic anticoagulant should be replaced by I/M low
molecular weight heparin 
 In high risk pt. risk of death from excessive bleeding less than from stroke if bridging therapy
is omitted 
 Pt with intracoronary stenting -> receiving anti platelet is at the risk of MI if stop
anticoagulant abruptly
 Current guideline recommends postponing all mandatory surgery until at least 1 month after
any coronary intervention  and suggest treatment options other than drug eluting stent be used
in patient expected to undergo a surgical procedure within 12 months after intervention
 When in doubt always consult a cardiologist
GASTROINTESTINAL
COMPONENT
Mendelson 1946 report ->aspiration of gastric content has disastrous pulmonary complication of
surgical anesthesia
In certain groups of pt. there is increased risk of aspiration ->pregnant women in 2nd and 3rd
trimester ,those with GERD
There is no good data to support restricting fluid intake more than 2 hours before induction of
general anaesthesia in healthy patients, non diabetic patient who drink fluid containing
carbohydrate and proteins up to 2 hr. before induction suffer less perioperative nausea and
dehydration than those who are fasted longer 
ELEMENTS OF PREOPERATIVE
PHYSICAL EXAMINATION
 Physical examination may detect abnormalities non apparent from the history and history
helps focus the physical examination 
 Including monitoring (BP,HR,RR,TEMPARTURE)
 examination of airway
 Heart
 Lungs ,
using standard technique of inspection palpation percussion and auscultation before administrating
regional anesthesia or inserting invasive monitors one should examine the relevant anatomy ,infection,
anatomic abnormalities near the site may contraindicate the planned procedure 
AIRWAY ASSESSMENT
 Anesthetic should examine the patient airway before every procedure (loose or chipped
teeth ,caps ,bridges ,dentures should be noted
 Poor fit of anesthesia mask ,Micrognathia , prominent upper incisors, large tongue, limited range of
motion of temporomandibular joint or cervical spine short or thick neck->suggest difficult
intubation , Mallampati score is often recorded
AIRWAY ASSESSMENT
 Factors that increase the risk of a difficult bag-valve-mask ventilation include facial hair,
obesity, being edentulous, advanced age, and history of snoring. These features can be
identified with a first glance assessment by the practitioner.
 Dentition should also be assessed and dentures should be removed for intubation. However,
dentures may need to be left in place for noninvasive airway management.
 Mouth opening can be assessed by using fingerbreadths. The patient can be asked to open his
or her mouth quickly at the bedside. The mandibular opening should be at least 4 centimeters
in adults, which is approximately three to four fingerbreadths.
 The distance between the mentum and the hyoid bone can also be measured and should be
three to four fingerbreadths. If the patient has a small mandible, they are more likely to have a
tongue obstruction which can impair the view when intubating. A large mandible can also
attribute to a difficult airway by elongating the oral axis and impairing visualization of the
vocal cords.
AIRWAY ASSESSMENT
 The patient's neck mobility plays a role in airway assessment as well. The ideal position for
intubation is the "sniffing position." The sniffing position requires flexion of the neck to 35
degrees and head extension to 15 degrees. Neck immobility interferes with the ability to align
the pharyngeal axis, oral axis, and laryngeal axis. Neck mobility can be impeded by a cervical
collar or structural changes including a fracture, dislocation, or arthritis
 Patients can be asked to protrude the lower jaw or bite their upper lip. The upper lip bite test
assesses the patient's ability to place their lower incisors over their upper lip. This acts as a
predictor of the ability to subluxate the mandible during laryngoscopy. The grading system is
as follows:

 Grade 1: the patient can fully cover the upper lip with the lower incisors
 Grade 2: the patient can partially cover the upper lip with the lower incisors
 Grade 3: the patient cannot reach the upper lip with lower teeth
PREOPERATIVE LAB TESTING
 Routine laboratory testing is not recommended for fit and asymptomatic patient
 Ideally testing should be guided by history , physical examination and nature of proposed
surgery e.g. Hb, HCT->in a patient with extensive blood loss
 There is avoidable increased preoperative risk when the results are abnormal 
 Use test having a low rate of false-positive and false-negative , specific have a low rate of
false -vee
PRE-OP INVESTIGATIONS CURRENTLY
RECOMMENDED BY DEPT. OF ANESTHESIA FATIMA
MEMORIAL HOSPITAL
Labs  Patient category
CBC All patients
S. Creatinine Age > 50 Yrs.
BUN HTN
D.M
B. Glucose DM
Vascular Disease
On Steroids
PFTS COPD with Dyspnea Grade>3
Respiratory Cripple
Acidotic Patients
Sat Less 92% on Room Air.
Patients on Ventilator
Patient on Oxygen Therapy
Electrolytes Age > 65Year                               Heart Diseases            
HTN                                               Chronic Illness       
D.M                                               On Diuretics + Drugs Steroid
CRF                                               On Parenteral Nutrition (TPN)
Emergency  Laparotomy            Vomiting (Moderate)
Chr . Liver Disease                      Patient on Ventilator
DM                                                  Pts having CV Line

CXR age>50Year           
Smoker              
Chronic Cough
COPD, Asthma
Respiratory Tract Infection
IHD/CCF
Anticipation of Prolong Surgery  OR Post op Ventilation
H/O Dyspnea ,Orthopnea
H/O Pulmonary Tb
If Large MNG Then Chest X-ray with Thoracic inlet

LFTs H/o recent jaundice

Hepatobiliary surgery
Hepatitis a/b/c/d/ e +ve
Patients on parenteral nutrition  (tnp)
ABGs Patients on Ventilator
Sat Less 92% on Room Air.

Coagulation Profile Deranged LFTs

PT/APTT/INR PIH/eclampsia
DIC & Sepsis 
On anti Coagulants
H/O Brusing / Excessive Bleeding
Family History of Bleeding Disorder

ECG Age > 40Year

HTN
H/O Dyspnea , Orthopnea
CRF
COPD, Asthma
H/O Chest Pain
H/O Chest Injury
Previous Cardiac Surgery
H/O Arrythmias
Ischemic Heart Disease
INTERNATIONAL GUIDELINES ON PREANESTHETIC
TESTING
(BASED ON ARTICLE:
ROUTINE PREANESTHETIC TESTING, PEDRO IBARRA
COUNCIL MEMBER WORLD FEDERATION SOCIETY OF ANESTHESIOLOGISTS, SOFIA
BOGOTA,
PUBLISHED 5TH OCTOBER 2021
Table 2. Summary of National Institute for Health and Care Excellence Recommendations.18 ASA indicates American Society of
Anesthesiologists
PREMEDICATION
 Study shows preoperative visit from anesthetist resulted in greater reduction in patient anxiety
than preoperative drugs
 All patients benefited from preoperative sedation and anticholinergics often combined with
opioid
 Outpatient surgery and same day hospital admission->preoperative sedative hypnotics ->never
administered before patient arrives in preoperative holding area for elective surgery
 Children aged 2 to 10 years ->experience separation anxiety may benefit from premedication
administered in preoperative holding area
PREMEDICATION
 Oral or I/V midazolam (2-5mg) or nasal dexmedetomidine are common methods
 If painful procedures will be performed while the patient remains awake ,small doses of opioid
often given
 In airway surgery or extensive airway manipulation benefit from preoperative administration
of anticholinergic agent ( glycopyrrolate or atropine) to reduce airway secretion before and
during surgery 
 Patient expected to have more significant amount of postoperative pain will be given
multimodal analgesics
DOCUMENTATION
 Physicians should provide high quality, safe and cost efficient medical care 

They also must document the care that they provide

It provides guidance to those who will encounter the patient in the future it permits others to
assess the quality of the care that was given and to provide risk adjustments of outcomes
PRE OPERATIVE ASSESSMENT
NOTES
INTRAOPERATIVE
ANESTHESIA RECORD
Anesthetic care in the operating room includes the following elements:
 That there has been a preoperative check of the anesthesia machine and other relevant
equipment
 That there has been a reevaluation of the patient immediately prior to induction of anesthesia
(a TIC requirement)
 Time of administration, dosage and route of drugs given intraoperatively
 Intraoperative estimates of blood loss and urinary output
 Results of laboratory test obtained during the operation (when there is an AIMS linked to an
electronic medical record such testing may be recorded elsewhere
 Intravenous fluids and any blood products administered
 Pertinent procedure notes.. (e.g.  for tracheal intubation or insertion of invasive monitors)
 Any specialized intraoperative techniques such as hypotensive anesthesia, one lung
ventilation, high frequency jet ventilation, or cardiopulmonary bypass
 Timing and conduct if intraoperative events such as induction, positioning, surgical incision,
and extubation
 Unusual events or complications (e.g. cardiac arrest)
 Condition of the patient at the time of handoff to the post anesthesia or intensive care unit
nurse
POST OPERATIVE NOTES
 In the united states as of 2009 the centers for Medicare and Medicaid services require that
certain elements should be included in all postoperative notes
 Respiratory function including reparatory rate airway patency and oxygen saturation
 Cardiovascular function including pulse rate and blood pressure
 Mental status
 Temperature
 Pain
 Nausea and vomiting
 Postoperative hydration
Thank you