PRE-OPERATIVE

ASSESSMENT
 objectives
• Introduction
• Routine preoperative assessment
• Preoperative evaluation and preparation
• Anesthetic plan
• Premedication
 Introduction
• Pre-operative visits are conducted in a
timely manner to provide standardized,
essential, evidence-based, preoperative
information to anesthesia and surgical care
teams.
• The pre operative assessment designed to
present the patient for surgery in the best
possible condition.
• In the past, patients were admitted to the
hospital at least a day prior to surgery.
• Currently, more and more patients are
admitted to the hospital on the day of
surgery.
 Cont..
• First the anesthesiologist performing the
anesthetic patient assessment prior to
anesthesia and surgery.

• So, the role of anesthetist begins not in the

operating theatre but in the ward.

• However, preoperative screening clinics are

becoming more effective and clinical practice
guidelines becoming more prevalent.
 cont….
• Finally, Anesthesiologists are
responsible for ordering preoperative
laboratory tests, in formed consent
and cancellations of planned surgical
procedures become less likely.
 purpose of visit
• preoperative anesthesia evaluation has benefits
for the patient, the anesthesiologist, the
surgeons, and the hospital.
1. For the patient:
- reduce anxiety.
- education regarding different types of
anesthesia, options for post-op analgesia.
- discuss medications and which ones they should
continue/discontinue.
 cont..
2. For the anesthesiologist:
- learn of patient’s medical conditions which
might influence anesthetic management.

- devise an anesthetic plan prior to day of

surgery

- allow time to discuss medical conditions with

consultants and/or order further testing.
 cont..
3. For the surgeons and hospital:

- decrease the cost of perioperative care

- improve the efficiency on day of surgery

- decrease the number of cancellations and

delays for surgery.
 APPROACH TO THE
PATIENT
• The preoperative evaluation form is the
basis for formulating the best anesthetic
plan tailored to the patient.

• It should aid the anesthesiologist in

identifying potential complications, as
well as serve as a medico legal
document.
 cont..
• The approach to the patient should always
begin with a thorough history and physical
exam. This alone may be sufficient (without
additional routine laboratory tests) prior to
non invasive procedures.

• The indication for the surgical procedure is

part of the preoperative history, because it
will help determine the urgency of the
surgery.
 cont..
• True emergent procedures, which are
associated with an accepted higher
anesthetic morbidity and mortality,
require a more shorten evaluation.
• A less-defined area is the approach to
urgent procedures.
• For example, ischemic limbs require
surgery soon after presentation, but can
usually be delayed for 24 hours for
further evaluation.
 cont..
• The indication for the surgical procedure
may also have implications on other
aspects of preoperative management.

• For example, the presence of a small

bowel obstruction has implications
regarding the risk of aspiration and the
need for a rapid sequence induction.
 cont..
•. Preoperative care of the patient, as
well as efficiency in the operating
room, is always better by close
communication with the surgeons.

• The ability to review previous

anesthetic records is helpful in
detecting the presence of a
-difficult airway,
-a history of malignant
hyperthermia, and the individual's
response to surgical stress and specific
anesthetics.
 cont..
• Guided by the above, the anesthesiologist
should choose the appropriate anesthetic and
care plan.

• Finally, the process should be used to educate

the patient about anesthesia during the
preoperative period, answer all questions,
and obtain informed consent.
 cont..
• The patient should be questioned regarding
any previous difficulty with anesthesia or

 other family members having difficulty with

anesthesia.

 A patient history relating an allergy to

anesthesia should make one suspicious for
malignant hyperthermia.
 cont..
• The history should include:- a complete list of
medications, including over-the-counter and
herbal product to define a preoperative
medication treatment, anticipate potential
drug interactions, and provide clues to
underlying disease.

 A complete list of drug allergies, including

previous reactions, should also be obtained.
 cont..
• The anesthesiologist should determine
when the patient last as well as note the
sites of preexisting intravenous
cannula,and invasive monitors.

• Once the general issues are completed,

the preoperative history and physical
exam can focus on specific systems.
 History
• Any problems encountered during past
anesthetics must be fully Investigated.

• Records of previous occasions yield a wealth of

information on response to various drugs,
intubation difficulties, allergic responses .

• Family anesthetic history is also important

because certain abnormal and
 cont..
Possibly dangerous responses to drugs
(e.g.malignant hyperpyrexia),post op
jaundice, Suxamethonium apnea) tend to
run in families.

Further, several diseases which can give

rise to"anesthetic problems" for Instance
sickle cell disease, dystrophic myotonica
and blood dyscrasias,have a hereditary
incidence.
 Medical history
• Respiratory problems:
 cough (dry or productive), smoking, asthma,
breathlessness,Chest pain and exercise tolerance.
History of previous chest disease
(TB, Bronchitis, broncholitis,
bronchoectatis ,neoplasm of the lung etc)
 cont..
A screening evaluation should include questions
regarding the history of
 tobacco use,
 shortness of breath,
 wheezing,
 stridor, and snoring or sleep apnea.
The patient should also be questioned regarding
the presence or recent history of an upper
respiratory tract infection.
 cont..
Cardiovascular problems
.
 Difficulty in breathing,
 palpitation,
 chest pain,
 ankle oedema,
 orthopnea ,
 Weight gain
 Previous heart attack
 Exercise tolerance
 Hypertension
 cont..
• Hypertension is divided into three stages
Stage 1. BP> 140/90-159/99mmHg.
Stage 2.BP 160/100-180/109mmHg.
Stage 3.BP>180/110 mmHg.
- It is important to know whether the
patient has acute or chronic hypertension
• If the patient has acutely elevated
HTN(white coat HTN) because the patient
is intense or in an uncomfortable
condition, it is better to treat anxiety with
diazepam.
 cont..
• If it is chronic hypertension, you should confirm that
whether there is second organ damage or not.
1.Why do you fear hypertension intraoperatively?
2.When hypertensive patient can show sign and symptom?
3.Which types of hypertension should be feared
more ,systolic or diasytolic?explain your reason.

4.In which circumstances HTN patient can undergo surgery?

5.How can you diagnosis hypertensive patient?
6.Hypertension emergency or urgency that has second
organ damage?
7.What does hypertensive crisis mean?
 cont..
• Depending on the patients condition
history related to other systems like
 renal,
liver or GIT
Neurological,
musculoskeletal system and genito
urinary system etc should also be asked.
 cont..
• Other illnesses, e.g. diabetes, renal disease,
hiatus hernia, epilepsy, trauma and malaria
should be asked.
sign of hyper or hypothyroidism
Alcohol and drug intake
Allergies
Smoking habits
 chewing chat
Surgical history
• Past surgical procedures as well as that for which
the patient is being assessed are important
 cont..
Some operations, such as those on the heart,
lungs, kidneys and CNS may tend to interfere
with vital functions under anesthesia.

Drug history(medication)
• The following drugs, previously or currently
being taken may influence present
anesthesia.
Steroids
• Prolonged steroid therapy (> 10mg
prednisolone/day) results -
 cont..
Atrophy of the adrenal glands so that they
cannot secrete extra hormones in time of
stress.

Collapse, with a fall of blood pressure, may

ensue many different regimes have been
described to provide preoperative steroid
cover.

The principles are as follows:

hydrocortisone sodium succinate (rapidly
acting) is the drug most frequently used.
 cont..
• Steroid cover is provided if the patient has
had steroids in the three months before
surgery unless the surgery is very minor and
imposes very little stress on the patient.

• Hydrocortisone is administered at induction.

• Dose: 25mg IV (adult)

• Any unexplained fall in blood pressure either

during or after surgery is treated with
steroids.
 cont..
-However hypotension from more common
causes such as blood loss or hypoxia must
be excluded.

The steroid cover is maintained until the

stress of the operative and post-operative
period is over and then gradually reduced.
 cont..
Antihypertensive drugs
- These drugs produce their effect by a
reduction in peripheral vascular tone.
This tends to interfere with circulatory
homeostasis under anesthesia.
Most patients are left on these tablets until
the day of operation.
The anesthetist must bear in mind that
these patients cannot compensate for such
stresses as:-
 cont..
blood loss,
changes in posture,
 intermittent positive pressure ventilation
(IPPV), etc. in the same way as normal
patients can.

Further, they may react badly to drugs such as

thiopentone which can cause a fall in blood
pressure.
 cont..
Monoamine oxidase inhibitors (MAOI)
-The actions of these drugs are imperfectly
understood. They interact with narcotic analgesics,
e.g. pethidine and morphine and result in various
reactions –
severe hypo or hypertension, coma, convulsions,
Cheyne Stokes respiration and death. They also react
abnormally with pressor drugs and
potentiate the side effects of barbiturates.
 cont..
The effects of MAOI last from 1 to 2 weeks
depending on the drugs.
Suspension of MAOI will be necessary for
major surgery requiring post-operative
analgesia.
This must be done 10 to 14 days pre-
operatively.
Beta-blockers
Commonly used for the treatment of
hypertension, cardiac arrhythmias,
ischaemic heart disease etc.
 cont..
Insulin
- Patients on antidiabetic treatment must
be carefully assessed by the anesthetist
for pre and post-operative care.
Oral hypoglycemic agents:-
metformin ,sulfonyl urease,acarbose
Antibiotics
-Large parenteral doses of antibiotics
neomycin, streptomycin and others
have been known to potentiate the action
of non-depolarising relaxants.
 cont..
Phenothiazines
-These cause peripheral vasodilatation
and result in a fall in blood pressure
under anesthesia.
They also potentiate the action of
narcotics and barbiturates
These drugs must be used in smaller
doses
 cont..
In most cases the patients may remain
on these drugs but remember that
they cannot compensate efficiently, in
the face of cardiovascular stress.
Diuretics
Prolonged diuretic therapy interferes
with electrolyte balance.
This must be checked pre-operatively
(especially potassium).
 cont..
Anticoagulants
-Many patients are on some form of
platelet inhibitors. While single agent
therapy poses no problem for most
operations, multi-modal platelet
inhibition may increase the risk of peri-
operative bleeding.
Non-steroidal anti-inflammatory agents
(NSAIDs, including aspirin (ASA))
These can be safely continued unless
there are special surgical (aesthetic
plastic surgery, neurosurgery) or
anesthetic (nerve block) considerations,
or the patient is on multi-modal therapy.
 cont..
• Many surgeons, however, want ASA
discontinued 2weeks prior to surgery and
other NSAIDs stopped for at least several days
even though we lack evidence that this alters
the incidence of intra-operative blood loss.
Actually, it may increase the incidence of
thrombotic complications (deep vein
thrombosis (DVT), coronary thrombosis,
thrombotic stroke), and prevent the pre-
emptive analgesia and opioid-sparing
capacity of pre-operative NSAIDs.
 cont..
These should be stopped prior to surgery and
can be reversed with transfusion of platelets.
However, patients on these agents usually
need
the anticoagulation. These drugs represent a
contraindication to RA.
Heparin Subcutaneous prophylactic dosing
probably need not be discontinued unless a
regional anesthetic is to be administered (4 h)
, but Lovenox® (low molecular weight heparin)
should be stopped 12 h before surgery.
 cont..
Herbal remedies
Public enthusiasm for herbal supplements has
its drawbacks. The following are
current considerations together with the
recommended discontinuation period prior to
surgery:
 Ephedra – works like ephedrine with direct
and indirect sympathomimetic effects and all
the consequent side effects including intra-
operative hemodynamic instability
 cont.
instability
. from depletion of endogenous
catecholamines; 24 h
 Garlic – inhibition of platelet aggregation and
increased fibrinolysis; 7 d
 Ginkgo – inhibition of platelet-activating factor;
36 h
 Ginseng – hypoglycemia, inhibition of platelet
aggregation; 7 d
 St. John’sWort – induction of cytochrome P450
enzymes; 5 d
 Others are sedatives such as Kava and Valerian,
perhaps reducing the need for
additional sedative agents – titrate!
 PHYSICAL EXAMINATION
• General examination
Note the following:
• General appearance of the patient in bed including
age and approximate weight.
For instance, is the patient dyspnoeic? Nervous?
Sweating, in pain? Or

• suffering from anemia, cyanosis, jaundice, edema,

dehydration (any
• evidence of early dehydration must be detected.
 cont..
Note skin turgor, tongue,
urine output, pulse, superficial veins etc).
Note temperature.

Sign of chronic sick looking or chronic illness

including :-
Wasted extremities ,xygomatic bony
prominence, baggy panty dermatosis etc
should be carefully seen
 cont..
Pathological problems: difficulty in opening
the jaws, difficulty in
extending the neck, tumours or
inflammation of the neck, burns and
contractures of the neck.

Finally, assess the psychological state of the

patient. This will influence the choice
between regional or general anesthetic and
also the premedication required.
 cont..
Airway examination
Note any anatomical features that would
hinder the maintenance of a clear
airway or interfere with Endotracheal
intubation, e.g. bull neck, large tongue
receding lower jaw, high arched palate or
protruding teeth edentulous teeth.
A simple and easy test known by the name of
Mallampati, who first described it, involves
sitting in front of the patient and asking them
to open their mouth fully and stick their
tongue out.
 cont..
If the faucial pillars, soft palate, posterior
pharyngeal wall and uvula are visible
laryngoscope should not be difficult.

The likely degree of difficulty increases as

less of the anatomy is visible and if only the
hard palate or both soft and hard palate
is /are visible a difficult laryngoscope is
probable.
 cont..
• Mallampati classification and view obtained
Class 1. Faucial pillars, soft palate and uvula.
Class 2. Faucial pillars and soft palate visible &
Uvula is masked by base of the tongue.
Class 3. soft palate and hard palate are Visible.

Class 4. Soft palate not seen/only hard palate is

visible.
This test is useful but is not substitute for a good
history and examination.
 cont..
Thyromental distance(TMD) >6-6.5cm
Sternomental distance(SMD)>12-12.5cm
Inter incisor gap or mouth opening more than>3F.
The distance from hyoid bone to chin >3F
inter incisor gap is used to assess mobility of TMJ.
 cont..
LEMON LAW
L-Look externally:-bull neck ,edentulous teeth,
normal face and neck, obesity etc.
E-Evaluate 3.3.3/2.1
M-Mallampati
O-Obstruction:-airway edema,epiglotitis etc
N-Neck mobility can fully extend or flex the neck
Evaluate 3.3.3.2.1 rule
 cont..
• Evaluate 3-3-2-1 Rule
3 Fingers between the patient’s teeth
Temporomandibular Joint exam
3 Fingers between the tip of the jaw and
the beginning of the neck.
2 Fingers between the thyroid notch and
the floor of the mandible.
1 Finger Lower Jaw Anterior Sublaxation
 cont..
• Predictors of Difficult Bag and Mask
Ventilation (Langeron et al)
~Summarized in one word O.B.E.S.E
- The Obese (body mass index >26kg/m2)
- The Bearded
- The Elderly (older than 55y)
- The Snorers
- The Edentulous
•
 System Examination
RESPIRATORY SYSTEM
Inspection
Note rate and type of breathing is it noisy,
kasmual, paradoxical.
Shape of chest and movement of the chest.
Deformities of the spine.
Sputum colour, quantity (if any) of nasal discharge.
Cyanosis central or peripheral.
Clubbing of fingers.
Use of accessory muscle.
 cont..
Palpation
Confirm chest movement.
Note the position of the trachea. it is central or
slightly deviated to the right.
Chest expansion is symmetrical or not
Tactile fremitus is symmetrical or not
tenderness
Check for the presence of enlarged supraclavicular
lymph nodes.
 cont..
Compare the percussion notes at equivalent
positions on both sides of the chest.
Resonant
Hyper resonant
Relative dullness
Stony dullness
 cont..
Auscultation
Breath sounds.
Normal breath sound(vesicular)
Abnormal breath sound like: crepitations,
rhonchi,stridor,wheezing ,BBS(Bronchial
breath sound)
Vocal resonance.
 cont..
Cardiovascular system
inspection
 position of apical impulse
 Colour of mucous membrane: cyanosed or
anaemic.
 Oedema (especially dependent)
 Clubbing
 cont..
Inspection and palpation
 To detect and confirm the position and quality
of the apex beat.

 Displacement of the apex beat may suggest

cardiac enlargement.

To confirm also the presence of any heave or

thrills over the precordium.
 cont..
The pulse Note the rate, rhythm, volume and
character of the pulse wave and vessel wall.

 Check the peripheral pulses, including arterial

pulsations in the neck.
Jugular venous pressure raised or not
Blood pressure
 cont..
Auscultation
 presence of murmur or gallop and bruit.

 Auscultation and percussion can also help us to

know presence of dextrocardiography (complete
location of the heart on the right side of the
chest).
 cont..
Abdominal examination
-check for solid organ enlargement(spleen or
liver),fluid thrills and shifting dullness.

-Other system examination should be done

based the patients condition.
 INVESTIGATIONS
These depend on the facilities available.
In the smaller hospital urinalysis and Hb
may be all that is available.

- In a larger hospital, some or all of these

tests may be considered routine,
depending on the patient and the surgery
CBC or at least haemoglobin.
 cont..
• Urinalysis
• Chest x-ray where indicated
• ECG in patients with a history of cardiac
disease
• BUN/creatinine and serum electrolytes
 con..
Specific investigations
This depends on the underlying medical
condition of the patient.
If there is respiratory disease:
Lung function studies: vital capacity and
forced expiratory volume
(FEV1), arterial blood gases
Sputum culture and sensitivity
CBC ,CXR, spirometry(if COPD)
More specialized radiological examination
 cont..
e.g Bronchoscope, etc
-If there is liver disease:
liver function tests and prothrombin
index
-If the patient is cardiac ,CXR ,ECHO ,ECG
-If there is diabetes. Four hourly blood
(glucometer) or urinalysis (in the ward) for
sugar and acetone
Fasting blood suger,glucose tolerance test
 cont..
If the patient is anaemic or the proposed
surgery would necessitate blood
transfusion then the patient's blood must
be grouped,RH,Hct and cross–matched.
If the patient is goiter thyroid function
test.
If renal disease, renal function test:-
BUN ,ceatinine,serum electrolyte and
sometimes uric acid. Others investigation
can be done in relation to the disease
condition
 ASA CLASSIFICATION
Assessment of physical status
The American Society of Anaesthesiologists
(ASA) has classified patients as follows
Class 1. A normal healthy patient.
2. A patient with mild systemic disease.
3. A patient with severe systemic disease
limiting activity but not incapacitating.
4. A patient with incapacitating disease – a
constant threat to life.
 cont..
 5. A moribund patient who is not expected to
survive without the operation and who come
to hospital for resuscitative effort. or A
declared brain dead patient whose organs
are being removed for donor purposes.
 If it is an emergency the category number
above should be followed by the letter E
(denoting emergency).
GENERAL PRINCIPLES (ELECTIVE AND EMERGENCY)

Any medical condition that can be corrected

or improved must first be treated so that the
patient is in the fittest possible physical state
before surgery.
The following are some medical problems
that may require treatment.
Anaemia
Depending on the time available for
treatment and the Hb deficit, iron deficiency.
 cont..
Anaemias may be treated with:
 oral iron
 parenteral iron
 blood transfusion
Anaemia must always be investigated before
treatment. Anaemia decreases the oxygen
carrying power of the blood.
(In anaemia grave hypoxia is not accompanied
by cyanosis). Ideally major surgery should not
be performed if the patient's Hb is less than 10g
%
 cont..
Sickle cell disease is a common cause of
anemia in patients from African and
Caribbean countries ,and
if there is a family history or any past
symptoms suggestive of a sickling crisis a
sickledex test should be performed if possible.

In sickle cell ,76% Hbs,the rest is foetal Hgb.

There is no HbA.
 cont..
Cardiovascular disease
 Myocardial infarction: A minimum of three
months and preferably six months, must be
allowed before elective surgery.
 Cardiac failure must be treated before elective
surgery.
 Arrhythmias: Arrhythmia is not a
contraindication for surgery but an attempt
must be made to correct the arrhythmia to the
best possible degree, e.g. in atrial fibrillation the
ventricular rate must be reasonably slowed with
digoxin or beta-blocker before anesthesia
 cont..
The arrhythmia must not be severe enough to
interfere with the patient's cardiac output.
Hypertension:
This must be treated pre-operatively. most
common fear of hypertensive patient under
going surgery :-bleeding ,uncontrolled
hypotension and ischemia. Uncontrolled
hypertension can also result in left ventricular
failure, arrhythmias and cerebrovascular
disturbances under anesthesia.
 cont..
 Clinical predictors of increased perioperative
cardiovascular risk (myocardial infarction, heart
failure,death)
Major
 Unstable coronary syndromes
 Decompensated heart failure
 Significant arrhythmias
 Severe valvular disease
Intermediate
 Mild angina pectoris
 Previous myocardial infarction
 cont..
 Compensated or prior heart failure
 Diabetes mellitus (particularly insulin-dependent)
 Renal insufficiency
Minor
 Advanced age
 Abnormal ECG (left ventricular hypertrophy, left
bundle-branch block, ST-T abnormalities)
 Rhythm other than sinus
 Low functional capacity, e.g., inability to climb one
flight of stairs with a bag of groceries
 History of stroke
 Uncontrolled systemic hypertension
 cont..
Respiratory disease
 Acute respiratory disease is a contraindication to
GA.
 Chronic respiratory disease e.g. COAD (Chronic
Obstructive Airways Disease) must first be
investigated and then treated with the usual
measures of physiotherapy, no smoking,
bronchodilators and antibiotics if necessary.
 Asthma must be treated with the appropriate
bronchodilators until the
chest is clear for auscultation, before elective surgery
is contemplated.
 cont..
Metabolic diseases
•Diabetes mellitus must be first investigated and
assessed and then controlled before elective
surgery is performed. The anesthetist must very
carefully work out a regime for the control of the
diabetic state during the operative period.

Liver disease especially in relation to the prothrombin

index. After a severe case of infective hepatitis,
operation is best postponed for a minimum of six
months.
 cont..
Thyroid disorders: Both hyperthyroidism and
hypothyroidism must be corrected before
elective surgery.

In addition to the problems of arrhythmias

and heart failure in the toxic patient the
danger of "thyroidstorm" occurring in the
post-operative period necessitates complete
control of the toxic state
 cont..
Chronic renal failure
Chronic renal failure (CRF) involves both the excretory
and synthetic functions of the kidney. When the kidney
fails to regulate fluids and electrolytes, the net result is
acidosis, Hyperkalemia, hypertension, and edema.

Meanwhile, the lack of synthetic function results in

anemia (due to decreased production of erythropoietin)
and hypocalcaemia from a lack of active vitamin D3 (this
also leads to secondary hyperparathyroidism,
hyperphosphatemia, andrenal osteodystrophy).
Azotemia cause platelet dysfunction. Medications that
are renally excreted will be affected by CRF, and most
should
be avoided.N/S is preferabable over R/L.
 cont..
Fluid Imbalance
Whenever possible the volume of circulating fluid
should be corrected before anaesthesia. Fluid
loss may result from a variety of causes, including
blood loss, burns, vomiting, diarrhoea, loss
through fistulae, loss into the gut (ileus), deficient
intake, excessive loss through the skin (especially
in the extremes of age) and excessive urinary
loss.
Briefly, the following symptoms and signs suggest
dehydration:
 cont..
 Thirst
 Dry mouth
 Diminished skin turgor
 Rapid pulse
 Decreased urine output
 In the later stages a fall in blood pressure
 Central venous pressure (CVP) if measured will
be low.
 A high BUN and a raised specific gravity of urine
confirm the diagnosis.
 cont..
Electrolyte imbalance
Sodium and potassium imbalance especially
must be corrected pre-operatively. A low
potassium level can result in hypotension,
arrhythmias and cardiac arrest. It can also
result in skeletal and smooth muscle
weakness and interfere with the action of
relaxant drugs. A high potassium level is also
associated with cardiac arrhythmias.
Fluid and electrolyte imbalance will be more common in
patients for emergency surgery.
 cont..
Smoking
This increases intra and post-operative
morbidity due to associated bronchial
exudation and bronchospasm. It should
ideally be given up three days pre-
operatively. However, cessation for even 24
hours pre-operatively reduces the morbidity.
If it is more than six months, the impact of
smoking most likely ceassed.
 SPECIAL PROBLEMS RELATED TO EMERGENCY SURGERY

In addition to the problems already listed,

patients presenting for emergency surgery pose
the problems of:
The unfasted patient (full stomach).
Hypovolaemia due to blood or fluid loss.
The unfasted patient (full stomach)
There is a dangers of vomiting or regurgitation
under anesthesia.
 cont..
In considering the pre-operative measures we can
take to prevent this complication, the following
deserve mention:
Postpone surgery for at least four to six hours.
However, the gastric emptying time is usually
prolonged in emergencies.

The stomach may be emptied using a naso-

gastric tube or orogastric tube of the largest
possible bore.
 cont..
 Sodium citrate (a non-particulate antacid) can be used
pre-operatively
to counteract the acidity of the gastric contents. It takes
approx. 10 minutes to work and its effects last approx.
20 minutes.

 H2 blockers i.e. ranitidine 300mg given at least 1 hour

prior to surgery may also decrease the acidity of gastric
contents.

 Metoclopramide10mg given at the same time may

benefit. Omeprazole 40mg given 2–6 hours prior to
surgery also helps reduce gastric acid.
 FASTING GUIDELINES
The most recent well-researched fasting guidelines
are as follows: -
For elective surgery
No solids after midnight or for 6 hours before
surgery but clear fluids can be allowed up to 2 hours
before surgery. (water, clear fruit juice without pulp,
black tea / coffee).

For babies and small children breast milk(contains

milk solid) may be allowed up to 4 hours before
surgery) and formula milk 6hours before surgery. but
for neonate formula milk may be allowed 4hours
before the surgery
 cont..
1. clear liquids 2hours
2. Breast milk 4hours
3. Formula milk
Neonate 4hours
infant 6hours
4. Non human milk 6hours
5. Solid 8hours
NB.ASA doesn’t guarantee an empty stomach.
Offering clear fluid up to 2 hours before induction
 reduce hunger and irritability
 preserves hydration
 decrease risk of hypoglycemia
 cont..
For emergency surgery
The period of fasting will depend on the urgency of
the procedure.
All emergency patients should be treated as
potentially at risk of aspiration and anaesthetised
using a rapid sequence induction.

Gastric emptying is delayed in the following

situations: patients is labour, with head injuries or
severe trauma and patients receiving drugs eg
opiates.
Very ill patients have a delayed gastric emptying time.
 PREMEDICATION
The term premedication is used to describe the
administration of drugs before operation, with the
general aims of lessening anxiety and fear and
contributing to the ease and safety of the
anesthetic.
The term was first used in 1920.
PURPOSES OF PREMEDICATION
 To alleviate anxiety and fear
 To reduce the volume and acidity of gastric
contents
 To reduce secretions especially salivary and
 cont..
 To prevent undesirable reflexes, e.g.
bradycardia.
 To provide anti–asthma and anti–allergy
therapy if relevant.
 To provide pre and post operative analgesia
 To reduce post-operative nausea and
vomiting.
 To facilitate induction and reduce the dose of
anesthetic required.
 cont..
DRUGS USED FOR PREMEDICATION
Narcotic, sedative and tranquillising drugs
Narcotic analgesics, e.g. papaveretum, pethidine, morphine.
These drugs are excellent agents for premedication.

Sedative drugs, e.g. barbiturates.

Tranquillizers, e.g. diazepam, midazolam, phenothiazines,
butyrophenones.
Sedative drugs and tranquillisers are useful when narcotics are
contraindicated. They are useful too when patients are not in
pain preoperatively and when they are to have a regional
anaesthetic.
The tranquilliser group of drugs is especially useful for patients
who are emotionally disturbed before the anaesthetic.
 cont..
Anticholinergic drugs
 Atropine, hyoscine (Scopolamine) and glycopyrrolate
are commonly used.
 Atropine has a more pronounced effect on the heart
(tachycardia).
 Hyoscine is a more effective drying agent. It also has a
central sedative effect and is a good antiemetic but
may cause confusion and restlessness in the elderly
patient, so is then used in smaller doses.
 Glycopyrrolate has the best drying action and the
least central effect.
 cont..
• Dosage of atropine = 300–600 micrograms
IV/IM
• Dosage of hyoscine = 200–600 micrograms
IV/IM/SC
• Dosage of glycopyrrolate = 200–400
micrograms IV
 cont..
Antacid drugs
For the management of an unfasted patient.
Anti-emetics
 Phenothiazines, butyrrophenones, antihistamines,
metoclopramide,
 hyoscine and 5HT3 antagonists e.g. ondansetron, can
be used to help reduce incidence of post-operative
nausea and vomiting.
No premedication
There is a place for no premedication in anesthesia. Very
ill and frail patients fall into this category.
eg .complicated malaria, severe myoxedema coma
 cont..
CHOICE OF DRUGS
The choice and dose of drugs will depend on a
variety of conditions.
 Age
 Sex
 Weight of patient
 Nature of surgery (long? painful?)
 Regional or general anaesthetic (relaxant with IPPV
or spontaneous breathing)
 Anticipated post operative pain
 cont..
Important points regarding choice of drugs
Narcotics such as papaveretum, pethidine or
morphine should be used.

(unless otherwise contraindicated) if the patient is in

pain, e.g. from a fractured femur.

Narcotics cause respiratory depression and should

not be used in head injured patients unless facilities
for pre and post-op long-term mechanical
ventilation are available.
 cont..
A sedative premedication should be
avoided in patients with raised intracranial
pressure.
Narcotics are avoided in Caesarean
sections and operative obstetrics,e.g.
forceps delivery.
They can be given when the baby is born.
Narcotic premedication is not used in
children under the age of twelve months.
 cont..
Smaller doses of narcotics are used in
Poor risk patients from whatever cause
-The elderly
- The very young
- Patients who should not be too drowsy at the end of the
operation, e.g. patients who have had surgery on the
upper airway, diabetic patients in whom prolonged
drowsiness may mask a hyper or hypoglycaemic state.

Papaveretum is given in a dose of 0.3 mg/kg.

Pethidine is given in a dose of 1 - 1.5 mg/kg.
Thank u!