Pre-operative Assessment

Done by:- Majed Alturkistani

History and Physical• Indication for surgery

• surgical /anesthetic Hx: previous anesthetics/complications, previous intubations, medications, drug allergies

• PMHx

• CNS: seizures, stroke, raised intracranial pressure (ICP), spinal disease

• CVS : coronary artery disease (CAD), myocardial infarction (MI), congestive heart failure (CHF), hypertension (HTN), valvular disease, dysrhythmias, peripheral vascular disease (PVD), conditions requiring endocarditis prophylaxis, exercise tolerance, NYHA class

• Respiratory: smoking, asthma, chronic obstructive pulmonary disease (COPD), recent upper respiratory tract infection (URTI), sleep apnea

• Gl: Gastroesophageal reflux disease (GERD), liver disease

• Renal: insufficiency, dialysis.

• Hematologic: anemia, coagulopathies.

• MSK: conditions associated with difficult intubations - arthritides (e.g. rheumatoid arthritis), cervical tumours, cervical infections/abscess, trauma to cervical spine, Down syndrome, scleroderma, obesity, conditions affecting neuromuscular junction (e.g. myasthenia gravis).

• Endocrine: diabetes, thyroid, adrenal disorders

• • other: morbid obesity, pregnancy, ethanol/other drug use

• • FHx: malignant hyperthermia. atypical

Functional Capacity or (METs)

• Defined as the ratio of metabolic rate (and therefore the rate of energy consumption) during a specific physical activity to a reference metabolic rate.

• 1 MET = 3.5 mL O2 uptake/KG per min

• O2 uptake of a 40 y/o, 70 kg male sitting upright

Specific Activity Scale1. Sit upright

2. Eat, dress, use toilet, make bed

3. Walk around house, shower

4. 1 flight stairs, walk up hill, 2 block @ 2mph

5. Light house work, dust, wash dishes, golf, bowl

6. 2 flights of stairs, walk on flat @ 4mph,

7. Sex

8. Scrubbing floors, weight lifting, moving furniture

9. Broke the bed/neighbors called the cops sex

10.Shovel snow

11.Doubles tennis, swing dancing

12.Recreational Sports: Singles tennis, soccer, basketball, skiing, jogging

13.Competitive sports

Relation To Surgery

• < 4 METs Significantly Increases Risk MI, HF, Arrhythmia regardless of Surgical Risk

• Functional Capacity Complication Rate

• < 4 METs > 5%

• 4 – 10 METs 1 – 5%

• > 10 Mets < 1%

Physical Examination• Airway.

• Focus Clinical systemic examination.

• Bony land mark for regional anesthesia.

• General assessment for nutrition, hydration and Mental Status.

• Pre-existing motor or sensory deficit.

• Site for IV, Central or PA catheter.

Airway Assessment• Likely hood of difficult intubation, Ability to assume

sniffing position.

• No single test specific or sensitive

• Mallampati score

• Thyromental distance

• Mouth opening

• Tongue size

• Dentition

Mallampati Score

Investigation

Fasting Protocol • 8 hours after a meal that includes meat, fried

or fatty food.

• 6 hours after a light meal such as toast and crackers) or after ingestion of infant formula or non - human milk.

• 4 hours after ingestion of breast milk or jello.

• 2 hours after clear fluid & (water,black coffee. tea carbonated beverages,juice without pulp).

ASA Classification

Optimization by medication• Medication

• Medication to start

• Aspiration \ Na citarte, Ranitidine.

• Infective Endocarditis \ AB.

• DVT Prophylaxis \ Heparine SC.

• Adrenal Suppression \ Steroid coverage.

• Anxiety \ Benzodiazpines

• Medication to stop

• Oral Hypoglycaemic + antidepressant.

• Medication to adjust

• insulin prednison, Coumadin and Bronchodialtor.

HTN• Mild to moderate HTN —> OK

• Target sBP < 180 mmHg , dBP <110mmHG.

CAD• <3 months after MI - 37% patients may re-

infarct.

• 3-6 months after MI -15%

• >6 months after MI - risk remains constant at 5%.

Thank You