Preoperative Patient

Assessment and Management

Medhanit D.
Yonas A.

1
Introduction
• The goals of preoperative evaluation are to reduce patient risk and the
morbidity of surgery, as well as to promote efficiency and reduce costs,
as well as to prepare the patient medically and psychologically for
surgery and anesthesia

2
Cont.
• General remarks
• Most medications for hypertension or cardiac disease should be
considered, and consideration should be given to initiating a beta-blocker
in patients at risk
• The need for subacute bacterial endocarditis prophylaxis should be anticipated
• For diabetic patients, oral hypoglycemic agents should often be held, but
patients requiring insulin will need to continue to take adjusted doses
• Drugs for asthma or COPD should be continued or administered
prophylactically
• Medications taken for the treatment of reflux should be continued, or
initiated for those patients with untreated symptoms
3
Approach to the Healthy
Patient

4
Introduction
• Always begin with a thorough history and physical examination
• The indication for the surgical procedure
• Review previous anesthetic records
• Define a preoperative medication regimen, anticipate potential drug
interactions, and provide clues to underlying disease
• Determine when the patient last ate
• Once the general issues are completed focus on specific systems

5
The Mallampati Airway Classification System

6
American Society of Anesthesiologists (ASA)
Physical Status Classification

7
Evaluation of the Patient with
Known Systemic Disease

8
Cardiovascular Diseases

9
Risk stratification
• Goldman cardiac risk index
• 6 independent predictors of complications were identified and included in a
revised risk index:
• High-risk type of surgery
• Preoperative treatment with insulin
• History of ischemic heart disease
• History of congestive heart failure
• History of cerebrovascular disease
• Preoperative serum creatinine >2.0 mg/dL

• Rates of major cardiac complications with 0, 1, 2, or 3 of these factors were 0.5, 1.3, 4, and 9%,
respectively

10
Cont.
• Clinical predictors of increased perioperative CV-risk
• Minor
• Advanced age
• Low functional capacity (e.g., inability to climb one flight of stairs with a bag
of groceries)
• Uncontrolled systemic hypertension
• History of stroke
• Abnormal ECG (left ventricular hypertrophy, left bundle- branch block, ST-T
abnormalities)
• Rhythm other than sinus (e.g., atrial fibrillation)

11
Cont.
• Cont.
• Intermediate
• Diabetes mellitus
• Mild angina pectoris (Canadian Class I or II)
• Prior myocardial infarction by history or pathologic Q waves
• Compensated or prior congestive heart failure

• Consider beta blockers

12
Cont.
• Cont.
• Major
• Unstable coronary syndromes
• Unstable or severe angina (Canadian Class III or IV)
• Recent myocardial infarction with evidence of important ischemic risk by clinical symptoms
or non-invasive study
• Decompensated congestive heart failure
• Significant dysrhythmias
• High-grade atrioventricular block
• Supraventricular arrhythmias with uncontrolled ventricular rate
• Symptomatic ventricular arrhythmias in the presence of underlying heart disease

• Consider beta blockers 13

Major risk determinants
• IHD
• The presence of unstable angina has been associated with a high
perioperative risk of MI
• For patients with a prior MI there’s increased incidence of reinfarction
if the MI was within 6 months of surgery
• With improvements in perioperative care, this difference has decreased
• General recommendations are to wait 4 to 6 weeks after MI to perform elective
surgery

14
Cont.
• Cont.
• Patients who have undergone a percutaneous coronary intervention with stenting
need to have elective non-cardiac procedures delayed for 4 to 6 weeks, although
the delay may be shortened depending on the type of stent used (drug eluting
versus non–drug eluting)
• The current AHA/ACC recommendations are to start β-blocker therapy in
medium- to high-risk patients undergoing major- to intermediate-risk surgery as
early as possible preoperatively and titrate to a heart rate of 60 beats per minute

15
Cont.
• DM
• DM accelerates the progression of atherosclerosis, so it is not
surprising that diabetics have a higher incidence of CAD than non-
diabetics
• There is a high incidence of both silent MI and myocardial ischemia
• Autonomic neuropathy in patients having DM has been found to be the best
predictor of silent CAD

16
Cont.
• Hypertension
• Patients are prone to perioperative myocardial ischemia, ventricular
dysrhythmias, and lability in blood pressure
• In the absence of end-organ changes, the benefits of optimizing blood
pressure must be weighed against the risks of delaying surgery
• Aggressive treatment of blood pressure is associated with increased
reduction in long-term risk, although the effect diminishes in all but diabetic
patients as DBP is reduced below 90 mm Hg
• There has been a suggestion in the literature that a case should be delayed if
the diastolic pressure is >110 mm Hg

17
Cont.
• Cardiac risk stratification for non-cardiac surgical procedures in patients
with known coronary artery disease

18
Evaluation
• ECG
• It has been estimated that approximately 30% of MIs occur without symptoms
(“silent infarctions”) and can only be detected on routine ECGs, with the highest
incidence occurring in patients with either diabetes or hypertension
• Abnormal Q waves in high-risk patients are highly suggestive of a past MI and
should alert the anesthesiologist to the increased perioperative risk and the
possibility of active ischemia
• The absence of Q waves on the ECG does not exclude the occurrence of a Q-wave MI in the
past
• Between 5 and 27% of Q waves disappear over the 10-year period following an infarction
• Confirmation of active ischemia usually requires changes in at least two leads

19
Cont.
• Echo
• It can assess cardiac ejection fraction at rest and under stress,
valvular area and function, regional wall motion abnormalities, and
wall thickness
• It is reasonable to have evaluations of left ventricular function for those with:
• Dyspnea of unknown origin
• Current or prior heart failure with worsening dyspnea or other change in clinical status
• Information regarding valvular function may have important implications for
either cardiac or non-cardiac surgery

20
Cont.
• Other
• Ambulatory ECG
• Stress test
• Coronary Angiography

21
Hypertension

22
Introduction
• The ACC/AHA guidelines list uncontrolled hypertension as a "minor" risk
factor for perioperative cardiovascular events

• Patients with preexisting hypertension are more likely to experience

intraoperative blood pressure lability, which may lead to myocardial
ischemia

23
Cont.
• Sympathetic activation during the induction of anesthesia can cause the
blood pressure to rise by 20 to 30 mmHg and the heart rate to increase
by 15 to 20 beats per minute in normotensive individuals
• These responses may be more pronounced in patients with untreated
hypertension in whom the systolic blood pressure can increase by 90 mmHg and
heart rate by 40 beats per minute

24
Cont.

JNC-8

25
Peri-operative risk
• The level of perioperative risk is dependent upon the severity of
hypertension
• Mild to moderate hypertension
• Patients with less marked hypertension (diastolic pressure less than 110 mmHg) do not
appear to be at increased operative risk
• The impact of systolic hypertension on operative risk is less clear
• Severe hypertension
• Studies have found that patients with untreated severe hypertension had exaggerated
hypotensive responses to the induction of anesthesia and marked hypertensive responses to
noxious stimuli 
• A diastolic pressure over 110 mmHg immediately before surgery is associated with a number
of complications including dysrhythmias, myocardial ischemia and infarction, neurologic
complications, and renal failure
26
Patients on chronic anti-hypertensive drugs
• For patients on chronic anti-HTNsive therapy, oral antihypertensive medications
should be continued up to the time of surgery
• Patients in whom chronic diuretic therapy has caused hypokalemia may have
potentiation of the effects of muscle relaxants used during anesthesia, as well as
predisposition to cardiac arrhythmias and paralytic ileus
• ACEIs and angiotensin II receptor blockers can theoretically blunt the
compensatory activation of the renin-angiotensin system during surgery and result
in prolonged hypotension
• It seems reasonable to continue these drugs in patients who are taking them for the
management of hypertension
• Withhold them on the morning of surgery in patients who are taking them for congestive
heart failure in whom the baseline blood pressure is low

27
Cont.
• Patients receiving calcium channel blockers may have an increased
incidence of postoperative bleeding, probably due to inhibition of platelet
aggregation

• Centrally acting sympatholytic drugs (e.g, clonidine, methyldopa,

and guanfacine) and the beta blockers should not be abruptly stopped
perioperatively

• Beta blockers reduce intraoperative myocardial ischemia

28
Post-op hypertension
• A history of hypertension preoperatively is the most important risk factor
for postoperative hypertension
• Other factors: pain, excitement on emergence from anesthesia, and hypercarbia
• Hypertension usually begins within 30 minutes of the completion of
surgery and lasts approximately two hours
• Some patients with preexisting hypertension may experience
normalization of blood pressure as a nonspecific response to surgery
• This response can persist for months, usually followed by a gradual return to
preoperative levels

29
Cont.
• Treatment
• Any patient who experiences a marked rise in blood pressure following surgery
should be treated immediately
• Remedial causes of hypertension such as pain, agitation, hypercarbia, hypoxia,
hypervolemia, and bladder distention should be excluded or treated
• Patients on chronic antihypertensive therapy should resume their usual
medications postoperatively as needed
• Those who cannot take oral medications should be given a comparable alternative
• Therapy should be considered for patients with a sustained systolic blood pressure
above 180 mmHg or diastolic blood pressure greater than 110 mmHg

30
Secondary hypertension 
• Ideally should undergo a diagnostic evaluation prior to elective
surgery
• However, most patients are not at increased perioperative risk as long as the
hypertension is not severe and serum electrolytes and renal function are normal
• An important exception is the patient with pheochromocytoma

31
Pulmonary Diseases

32
Introduction
• Pulmonary complications remain a major cause of morbidity and mortality for patients
undergoing surgery and anesthesia

• They occur more frequently than cardiac complications, with an incidence of 5 to 10% in
those having major noncardiac procedures

• Perioperative pulmonary complications include:

• Atelectasis
• Pneumonia
• Bronchitis
• Bronchospasm
• Exacerbation of COPD
• Respiratory failure requiring mechanical ventilation
33
Cont.
• General anesthesia results in mechanical changes such as a decrease in the
FRC and altered diaphragmatic motion leading to V/Q mismatch
• Inhibition of mucociliary clearance
• Inhibition of surfactant release
• Increased alveolar-capillary permeability
• Increased sensitivity of the pulmonary vasculature to neurohumoral mediators
• Increased nitric oxide synthetase

• Decreases in postoperative vital capacity and FRC, as well as diaphragmatic

dysfunction are contributing factors
• FRC may take up to 2 weeks to return to baseline
34
Cont.
• Factors affecting the occurrence and severity of pulmonary
complications
• General factors
• Specific lung related factors
• Surgery related factors
• Site
• Type
• Duration
• Anesthesia and post-op analgesia (narcotics)

35
Cont.
• General factors
• Increasing age
• Dependent functional status
• Obesity
• Malnutrition
• Weight loss
• Lower albumin level

36
Cont.
• Specific pulmonary risk factors
• Smoking
• OSA
• URTI
• Pneumonia
• COPD
• Dyspnea
• Preoperative sputum production

37
Cont.
• Surgery related factors
• The site and type of surgery are the strongest predictors of
complications
• Site: thoracic and upper abdominal surgeries are associated with the highest risk
for postoperative pulmonary problems
• Risk increases as the incision approaches the diaphragm
• Type: abdominal aortic aneurysm repair, thoracic, and upper abdominal surgery,
followed by neck, peripheral vascular, and neurosurgery
• Neurosurgery and neck surgery may be associated with perioperative aspiration pneumonia
• Duration: morbidity rates increase after 2 to 3 hours of GA
• Anesthesia and post-op analgesia

38
Smoking
• Smoking is known to:
• Decrease ciliary function
• Increase sputum production
• Airway hyperactivity
• Increase carboxy-hemoglobin levels
• Cause stimulation of the cardiovascular system secondary to the nicotine

• Management
• While cessation of smoking for 2 days can decrease carboxyhemoglobin levels, improve mucous
clearance, and abolish the nicotine effects, prospective studies show that smoking cessation for
at least 4 to 8 weeks was necessary to reduce the rate of postoperative pulmonary
complications
• Because smokers often show increased airway reactivity under GA, it is useful to administer a
bronchodilator such as albuterol preoperatively 39
Asthma
• Frequent use of bronchodilators, hospitalizations for asthma, and the
requirement for systemic steroids are all indicators of the severity of the
disease

• Management
• In general, the preoperative management of asthma is the same as for patients with asthma
not undergoing surgery
• In addition to bronchodilators, perioperative steroids are worth considering as prophylaxis for the
severe asthmatic
• Hydrocortisone 100 mg IV every 8 hours on the day of surgery
• For patients using inhaled steroids, they should be administered regularly, starting at least 48 hours
prior to surgery for optimal effectiveness
40
Evaluation
• Preoperative pulmonary function testing is usually reserved for those
scheduled for lung resection
• Age >60 years with major thoracic or abdominal surgeries
• Single lung ventilation
• Smokers
• Over lung pathology
• Comorbidites

41
Endocrine Diseases

42
Diabetes Mellitus
• Associated risks
• Microvascular
• Autonomic neuropathy
• Hemodynamic instability during anesthesia
• Arrhythmia and/or MI
• Aspiration
• Nephropathy
• AKI
• ?Retinopathy
• Macrovascular
• MI
• CVD
• PAD
• Positioning injuries
43
Cont.
• Anesthesia and surgery interrupt the regular meal schedule and insulin
administration of diabetics

• Perioperative stress may increase serum glucose concentrations

secondary to the release of cortisol and catecholamines

• A better glycemic control may limit morbidity and mortality of surgical

patients

44
Cont.
• Preoperative glucose management
• Schedule the surgery as the first case to prevent prolonged fasting
• At a minimum, an attempt should be made to control the glucose
within a range of 100 to 200 mg/dL
• Current recommendations are to maintain the perioperative glucose level
between 80 and 150 mg/dL

45
Cont.
• Cont.
• Type II DM
• Oral hypoglycemic agents are held on the day of surgery to avoid reactive
hypoglycemia
• The exception is metformin, which should be held for at least 24 hours preoperatively to
avoid the risk of drug-induced lactic acidosis (in the setting of renal insuffciency)
• Insulin should be continued through the evening before surgery
• Withhold long-acting insulin preparations (Ultralente preparations) on the day of surgery
• Lower dosages of intermediate-acting insulin (NPH or Lente) are substituted on the
morning of surgery
• Once a diabetic who is receiving nothing by mouth is given insulin, provide glucose in IV
fluids
• Patient should take a glucose tablet or clear juice if hypoglycemia occurs
46
Cont.
• Cont.
• Type I DM
• Patients should be continued on basal insulin replacement even while on
nothing by mouth status to prevent ketoacidosis
• Administer half the usual morning dose of intermediate- or long-acting
insulin

47
Cont.
• Intra-op and post-op management
• During surgery, a standard 5% or 10% dextrose infusion is used with
short-acting insulin or an insulin drip to maintain glycemic control
• Postoperative orders include frequent (every 2-4 hours) finger stick
glucose checks and the use of short-acting (Regular) insulin in the form
of sliding-scale coverage
• Twice-daily doses of intermediate-acting insulin can be supplemented with
sliding-scale coverage until the patient is eating and can resume the usual
regimen

48
Thyroid Disease
• The preoperative evaluation should focus on evaluating the signs and symptoms of
hyperthyroidism and hypothyroidism

• Hypothyroidism can lead to the development of hypothermia, hypoglycemia, hypoventilation

and hyponatremia, as well as a susceptibility to depressant drugs (anesthetic agents and
narcotics)
• Patients with newly diagnosed mild to moderate hypothyroidism generally do not require preoperative
treatment

• In a patient with hyperthyroidism, antithyroid medications such as PTU or methimazole are

continued on the day of surgery
• The patient's usual doses of β-blockers or digoxin are also continued
• In the event of urgent surgery in a thyrotoxic patient at risk for thyroid storm, a combination of adrenergic
blockers and glucocorticoids may be required and are administered in consultation with an endocrinologist
49
Renal diseases

50
Introduction
• Renal disease has important implications for fluid and electrolyte
management, as well as metabolism of drugs

• A preoperative creatinine level ≥2 mg/dL is an independent risk factor for

cardiac complications

51
Cont.
• A patient with ESRD should undergo dialysis before surgery to
optimize their volume status and control the potassium level
• This patients also require pharmacologic manipulation of hyperkalemia,
replacement of calcium for symptomatic hypocalcemia, and the use of
phosphate-binding antacids for hyperphosphatemia

• NSAIDs for postoperative pain control are avoided in patients with

renal insufficiency

52
Hepatobiliary diseases

53
Introduction
• Liver disease is associated with altered protein binding and volume of
distribution of drugs, as well as coagulation abnormalities

• A patient with acute hepatitis and elevated transaminases is managed

non-operatively, when feasible, until several weeks beyond normalization
of laboratory values
• A patient with evidence of chronic hepatitis may often safely undergo surgery

54
Cont.
• 2 common problems requiring surgical evaluation in a cirrhotic
patient are hernia (umbilical and groin) and cholecystitis
• Repair of groin hernias in the presence of ascites is less risky in terms of both
recurrence and mortality

• Malnutrition is common in cirrhotic patients

• Attention must be given to appropriate enteral supplementation

55
56
Hematologic diseases

57
Introduction
• Blood transfusion
• The standard regarding the lowest acceptable perioperative hematocrit and
indication for a preoperative transfusion has changed during the past decade
• The current recommendations are that a hemoglobin level of 7 g/dL is acceptable in patients
without systemic disease
• In patients with systemic disease, signs of inadequate systemic oxygen delivery (tachycardia,
tachypnea) are an indication for transfusion
• In patients with hemoglobin >10 g/dL, transfusion is rarely required

• Platelet transfusion
• When counts are less than 50,000 in a patient at risk for bleeding

58
Cont.
• In patients taking warfarin
• The drug is withheld for four scheduled doses preoperatively to allow the INR to
fall to the range of 1.5 or less (assuming that the patient is maintained at an INR
of 2.0-3.0)
• Systemic heparinization is started immediately after cessation of warfarin
• Heparin can be stopped within 6 hours of surgery and restarted within 12 hours
postoperatively
• Warfarin is co-initiated and continued until target INR

59
Cont.
• Other drugs
• Aspirin and clopidogrel are withheld for 7 to 10 days
• NSAIDs are withheld between 1 day (ibuprofen and indomethacin) and
3 days (naproxen and sulindac) depending on the drug's half-life
• Tamoxifen probably needs to be withheld for a period of 4 weeks
preoperatively
• It has been associated with an increased risk for thromboembolism

60
Cont.
• DVT
• When possible, surgery is postponed in the first month after an episode of
venous or arterial thromboembolism

• DVT prophylaxis
• Initial prophylactic doses of heparin can be given preoperatively, within 2 hours of
surgery, and compression devices are in place before induction of anesthesia

61
General considerations

62
Preoperative Laboratory Testing
• CBC and BG • Coagulation Studies
• Hepatic disease
• OFT
• Bleeding disorder
• Blood Glucose • Anticoagulants
• Physiologic age ≥75 years • Chemotherapy
• DM • Electrolytes
• CXR • Diuretic use
• Physiologic age ≥75 years • Diabetes
• Tobacco ≥20 pack-years • Renal disease
• Recent upper respiratory infection • CNS disease
• Pulmonary disease • Endocrine disorders
• Cardiovascular disease • Albumin
• ECG • Physiologic age ≥75 years
• Malnutrition
• Physiologic age ≥75 years
• Cardiovascular disease • Pregnancy Test
• Pulmonary disease • Possible pregnancy
• Diabetes • Urinalysis 63
Antibiotic Prophylaxis
• Appropriate antibiotic prophylaxis in surgery depends on
• The most likely pathogens encountered during the surgical procedure
• The type of operative procedure

64
Cont.
• Use depending on class of wound
• Prophylactic antibiotics are not generally required for clean (class I) cases, except in
the setting of indwelling prosthesis placement or when bone is incised
• Patients who undergo class II procedures benefit from a single dose of an
appropriate antibiotic administered before the skin incision
• Contaminated (class III) cases require mechanical preparation or parenteral
antibiotics with both aerobic and anaerobic activity
• Such an approach is taken in the setting of emergency abdominal surgery, as for suspected
appendicitis, and in trauma cases
• Dirty or infected cases often require the same antibiotic spectrum, which can be
continued into the postoperative period in the setting of ongoing infection or
delayed treatment
65
Cont.
• Antibiotics are given 1st dose 30 minutes before skin incision, then continued
for 24 hours
• For prolonged operations (>4 hours) or those with major blood loss, additional
intraoperative doses should be given at intervals 1-2 times the half-life of the drug for
the duration of the procedure in patients with normal renal function
• Half lives: Cefazolin 1.5 to 2 hrs, Cefoxitine 1 hr, ceftriaxone 6 to 8 hrs
• Choice of antibiotics
• For abdominal (hepatobiliary, pancreatic, gastroduodenal) cases, cefazolin is generally
used
• For colorectal surgeries: oral neomycine + oral erythromycin/metronidazole
• 1 g of neomycin plus 1 g of erythromycin at 1 pm, 2 pm, and 11 pm or 2 g of neomycin plus 2 g of
metronidazole at 7 pm and 11 pm the day before for an 8 am operation

66
Cont.
• Principles relevant to appropriate antibiotic prophylaxis for surgery:
• Select an agent with activity against organisms commonly found at the site of surgery
• The initial dose of the antibiotic should be given within 30 minutes prior to the
creation of the incision
• The antibiotic should be re-dosed during long operations based upon the half-life of
the agent to ensure adequate tissue levels
• If operation exceeds the serum drug half-life, patient should receive an additional dose
• The antibiotic regimen should not be continued for more than 24 hours after surgery
for routine prophylaxis
• Postoperative doses of an antimicrobial agent is costly and is associated with increased rates of
microbial drug resistance

• Prophylaxis is limited to a single dose administered immediately prior to creating the incision
(Schwartz) 67
Fasting Before Surgery
• The ASA adopted guidelines in 1998 that recommended a minimum fasting period of 2
hours after the ingestion of clear liquids and 6 hours for solids and nonclear liquids
such as milk or orange juice
• Clear liquids are defined as liquids that you can see through and do not contain solids or
particulates
• Summary
• Clear liquids: 2 hrs
• Breast milk: 4 hrs
• Solids, semi-solids and non-clear liquids (including non-human milk, formula): 6 hrs

• The use of agents to improve gastric emptying and neutralize gastric acid may be
warranted in patients who have medical conditions that cause decreased gastric
emptying
68
Preoperative Mechanical Bowel Cleansing
• MBP refers to the preoperative administration of substances to induce
voiding of the intestinal and colonic contents
• Suboptimal cleaning of the colon may be more problematic than no
bowel preparation at all
• MBP alone (without administration of oral antibiotics) should not be
used for the purpose of reducing SSI
• ?More recent studies state that oral antibiotics confer no benefit to the
patient and may increase the risk for postoperative infection with
Clostridium difficile

69
Cont.
• Possible harms of MBP
• Patient discomfort
• Potentially severe dehydration
• Electrolyte abnormalities

70
Hair removal
• Hair removal may be necessary to facilitate adequate exposure and preoperative
skin marking
• Furthermore, suturing and the application of wound dressings can be complicated by the
presence of hair
• Hair has been associated with a lack of cleanliness
• Its recommend that hair should either not be removed or, if absolutely
necessary, it should be removed only with a clipper
• To minimize the potential of skin trauma, the use of clippers instead of razors has been
proposed
• Hair removal with a razor promotes overgrowth of skin microbes in small nicks and cuts
• If hair is removed, removal shortly before surgery could be the most practical
and safest approach and should be outside of the OR
71
Preoperative Bathing
• Bathing with either a plain or antimicrobial soap the day of the operation
or the day before is recommended

72
Things to be removed pre-op
• Glasses
• Lens
• Dentures
• Partial plate
• Hair pins
• Make up
• Jewelry
• Underwear

73
Documentation
• Informed consent

74
Medication review
• Drugs that should be withheld before surgery
• Oral hypoglycemic agents
• 24 hours before surgery
• Anticoagulants/antiplatelets
• Warfarin for 4 doses
• Aspirin and clopidogrel for 7 to 10 days
• NSAIDs for 1 to 3 days
• Estrogen and tamoxifen
• For a period of 4 weeks preoperatively

75
End!

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