PREOPERATIVE ASSESSMENT

CONTENTS
1.

2.
3. 4. 5. 6. 7.

Objectives Preop assessment, where & when? Recommended preoperative investigations Fasting guidelines Premedication Medications Summary

OBJECTIVES
1. Confirmation of pt identification, review of diagnosis & proposed procedure 2. Thorough history: - medical history e.g: IHD, HPT, DM - surgical related history - anaesthetic - drug

History and physical are the most important assessors of disease and risk

OBJECTIVES
PREVIOUS ANAESTHETIC HISTORY difficult airway PONV Malignant hyperthermia allergies difficult IV access awareness death following anaesthesia in the family

OBJECTIVES
DRUG HISTORY - very useful, often forgotten Current medications Smoking/alcohol history History of allergy Medic alert bracelets Other drugs abuse

OBJECTIVES
3. Thorough Physical Examination: i) General examination: - General mental status, body weight
-

CVS blood pressure, heart murmur

RS - abnormal breathing sounds GI - abnormal masses, previous scar

OBJECTIVES
Musculoskeletal kyphoscoliosis
Skin local skin infection especially at

thoracolumbar area
Neurological peripheral neuropathy

OBJECTIVES
ii) Specific examination - directed to the disease e.g: cardiovascular disease young HPT look for sign for secondary causes

OBJECTIVES
4. Optimization of patients medical condition for anaesthesia -e.g: uncontrolled blood sugar/hypertension in diabetic patients

OBJECTIVES
5. Airway assesment - certain features of concern
obesity limited mouth opening poor dentition limited neck mobility

 scars/ surgery/ anatomical abnormalities neck mass mallampati scoring

MALAMPATI SCORING

FEATURES OF DIFFICULT INTUBATION

OBJECTIVES
6. Classify physical status
ASA grading (American Society of

Anesthesiologists)
Functional capacity

ASA GRADING
Medical co-morbidity increases the risk associated with anaesthesia and surgery ASA grading is the most commonly used grading system ASA accurately predicts morbidity and mortality

ASA Grade I

Definition Normal healthy individual Mild systemic disease that does not limit activity

Mortality (%) 0.05

II

0.4

III

Severe systemic disease that limits 4.5 activity but is not incapacitating

IV

Incapacitating systemic disease which is constantly lifethreatening

Moribund, not expected to survive 24 hours with or without surgery

25

50

Application of ASA Grading Cardiovascular disease

ASA Grade 2 ASA Grade 3

Angina

Occasional use of GTN. Well controlled on single agent Well controlled. No complications

Regular use of GTN or unstable angina

Hypertension

Poorly controlled. Multiple drugs

Poorly controlled or complications

Diabetes

Respiratory disease
ASA Grade 2 Cough or wheeze. Well controlled Well controlled with inhalers ASA Grade 3

COPD Asthma

Breathless on minimal exertion Poorly controlled limiting lifestyle

Functional Capacity
This is a measure of the metabolic demands of various daily activities on the heart
For e.g: a patient who was breathless at rest, or after walking a short distance, would have a low functional capacity, which is a predictor of increased risk

Functional Capacity
Poor functional capacity is associated with increased cardiac complications in noncardiac surgery.

A patient's functional capacity can be expressed in metabolic equivalents (METs). One MET equals the oxygen consumption of a 70kg, 40-year-old man in a resting state

Functional Status Assessment

Excellent (>7 METs) Squash Jogging (10minute mile) Scrubbing floors Singles tennis Moderate (4 to 7 METs) Poor (<4 METs)

Cycling, Climbing a flight of stairs Golf (without cart) Walking 4 mph Yardwork (e.g., raking leaves, weeding, pushing a power mower)

Vacuuming Activities of daily living (e.g., eating, dressing, bathing) Walking 2 mph Writing

OBJECTIVES
7. Planning of anaesthetic technique, perioperative care & pain management 8. Clarification with surgeon if required 9. Obtain consent - anaesthesia - surgical - blood transfusion

ANAESTHETIC DISCLOSURE AND CONSENT

-

Planned anaesthetic procedure Anaesthetic options if applicable Possible risks & complications pertaining to anaesthesia Benefit vs risks of each technique High risk consent with possible ICU admission

ANAESTHETIC CONSENT
- For underaged patient, obtain from parent/ guardian - Discussion should be documented

OBJECTIVES
10. Establishment of rapport - reduce anxiety & facilitate conduct of anaesthesia

11. Give instruction on medications, time of fasting 12. Prescription of premedicant drugs

PREOPERATIVE ASSESSMENT Where & when ?

1. Elective surgery - assessment done either in pre-anaesthetic clinic or ward - advantages of early referral Allows preoperative optimization Reduces risk of unnecessary cancellation Appropriate lab investigation can be done & reviewed

2. Emergency surgery ill patient will be assessed in the ward prior to surgery

May need ICU admission preoperatively

for stabilization

RECOMMENDED PREOPERATIVE INVESTIGATIONS

FBC Renal profile

- Age above 60
- Clinical anaemia - Haematological disease

- Age > 60
- Renal ds - Liver ds

- Renal disease
- Chemotherapy - Procedures with blood

- DM
- Cardiovacular disease - Procedures with blood

loss > 15%

loss >15%

RECOMMENDED PREOPERATIVE INVESTIGATIONS

ECG CXR

- Age > 50
- Cardiovascular disease - DM

- Age > 60
- Signs of significant

- Renal disease

respiratory disease - Cardiovascular disease

RECOMMENDED PREOPERATIVE INVESTIGATIONS

Coagulation profile RBS

- Haematological disease
- Liver disease - Anticoagulations

- Age > 60
- DM - Liver dysfunction

- Intrathoracic/

intracranial procedures

RECOMMENDED PREOPERATIVE INVESTIGATIONS

Liver function test

- Hepatobiliary disease
- Alcohol abuse

RECOMMENDED PREOPERATIVE INVESTIGATIONS

OTHER SPECIFIC INVESTIGATIONS 1. ABG 2. Lung function test 3. Thyroid function test

FASTING GUIDELINES
ADULTS PAEDS SOLID FOOD CLEAR FLUID BREAST MILK FORMULA MILK/ SOLID 6H 2H 4H 6H

PREMEDICATION
1. NO SEDATIVE PREMED - ill, septic, elderly - potential diff airway - day care surgery - most neurosurgical pts - neonates & infants < 6 month

PREMEDICATION
2. ORAL BENZODIAZEPINE (e.g midaz) - most elective pts - night & before sending to OT

PREMEDICATION
3. PAED PTS - Omit premed in ill babies, neonates & infants < 6 month esp prem babies - Syrup midazolam 0.2 mg/kg - EMLA cream

PREMEDICATION
4. OBSTETRIC PTS - Oral ranitidine 150mg ON & morning of op - 0.3M sodium citrate 30 ml - Iv metoclopramide 10 mg 5. PTS AT RISK OF ASPIRATION Prophylaxis vs acid aspiration - H2 receptor antagonist e.g ranitidine - Proton-pump Inhibitor e.g omeprazole

PREMEDICATION
- Non particulate antacids e.g 0.3M sodium

citrate - Gastrokinetic agents e.g metoclopramide

MEDICATIONS
Take all usual medications - Antihypertensives - blocker - Statins Think about discontinuing/ replacing - Aspirin - Anticoagulants - Diabetic medications - MAOIs

SUMMARY
Preoperative assessment is very important

History and physical examination are most

important assessor of disease and risk ASA and functional status are good predictors of risk Lab tests are useful and ordered when indicated