PREOPERATIVE EVALUATION

PREANESTHESIA EVALUATIONthe process of clinical assessment that precedes the delivery of anesthesia care for surgery and

for non-surgical procedures

Can or should the patient’s physical or mental Can or should the patient’s physical or mental condition be improved before surgery?condition be improved before surgery?

Does the patient have any health problems or Does the patient have any health problems or use any medications that could use any medications that could unexpectedly influence perioperative unexpectedly influence perioperative events?events?

GOALSGOALS of of preoperative preoperative evaluationevaluation

1.1. To reduce the morbidity of surgeryTo reduce the morbidity of surgery2.2. To increase the quality but decrease the cost To increase the quality but decrease the cost

of perioperative careof perioperative care3.3. To educate the patient about anesthesia, To educate the patient about anesthesia,

perioperative care, and pain treatmentsperioperative care, and pain treatments4.4. To reduce anxiety and facilitate optimal To reduce anxiety and facilitate optimal

recoveryrecovery

Routine Preoperative EvaluationHistoryPhysical examinationLaboratory evaluationASA physical status classificationObtaining informed consentFormulation of anesthetic plan

Routine Preoperative anesthetic evaluationRoutine Preoperative anesthetic evaluation

Current problemCurrent problemOther known problemsOther known problemsMedication historyMedication history

AllergiesAllergiesDrug intolerancesDrug intolerancesPresent therapy (prescription, nonprescription)Present therapy (prescription, nonprescription)Nontherapeutic (alcohol, tobacco)Nontherapeutic (alcohol, tobacco)IllicitIllicit

Previous anesthetics, surgery, and obstetric deliveriesPrevious anesthetics, surgery, and obstetric deliveriesFamily historyFamily historyReview of organ systemsReview of organ systems

GeneralGeneral NeurologicNeurologicRespiratoryRespiratory EndocrineEndocrineCardiovascularCardiovascular PsychiatricPsychiatricRenalRenal OrthopedicOrthopedicGastrointestinalGastrointestinal DermatologicDermatologicHematologicHematologic

Last oral intakeLast oral intake

HistoryHistory


Current problem Current problem determine surgical diagnosisdetermine surgical diagnosisindications for planned surgical procedureindications for planned surgical procedureexact nature of comtemplated surgical exact nature of comtemplated surgical procedureprocedure

Other known problemsOther known problemsMedication historyMedication history





HistorHistoryy


Current problemCurrent problem

Other known problemsOther known problems

Medication historyMedication historyAllergiesAllergiesDrug intolerancesDrug intolerancesPresent therapy (prescription, nonprescription)Present therapy (prescription, nonprescription)Nontherapeutic (alcohol, tobacco)Nontherapeutic (alcohol, tobacco)IllicitIllicit




HistorHistoryy


Current problemCurrent problemOther known problemsOther known problems

Medication historyMedication historyAllergiesAllergiesDrug intolerancesDrug intolerancesPresent therapy (prescription, nonprescription)Present therapy (prescription, nonprescription)Nontherapeutic (alcohol, tobacco)Nontherapeutic (alcohol, tobacco)IllicitIllicit




HistorHistoryy




Previous anesthetics, surgery, and Previous anesthetics, surgery, and obstetric deliveriesobstetric deliveries

Family historyFamily historyReview of organ systemsReview of organ systems



HistorHistoryy




Previous anesthetics, surgery, and obstetric deliveriesPrevious anesthetics, surgery, and obstetric deliveries

Family historyFamily history

Review of organ systemsReview of organ systemsGeneralGeneral NeurologicNeurologicRespiratoryRespiratory EndocrineEndocrineCardiovascularCardiovascular PsychiatricPsychiatricRenalRenal OrthopedicOrthopedicGastrointestinalGastrointestinal DermatologicDermatologicHematologicHematologic


HistorHistoryy




Previous anesthetics, surgery, and obstetric deliveriesPrevious anesthetics, surgery, and obstetric deliveriesFamily historyFamily history

Review of organ systemsReview of organ systemsGeneralGeneral NeurologicNeurologicRespiratoryRespiratory EndocrineEndocrineCardiovascularCardiovascular PsychiatricPsychiatricRenalRenal OrthopedicOrthopedicGastrointestinalGastrointestinal DermatologicDermatologicHematologicHematologic


HistoryHistory






Last oral intakeLast oral intake-- -- risk for aspiration of stomach contents when patient risk for aspiration of stomach contents when patient

is rendered unconscious by anestheticsis rendered unconscious by anesthetics-- ‘NPO’ for at least 6 hrs prior to elective surgery-- ‘NPO’ for at least 6 hrs prior to elective surgery-- delayed gastric emptying time expected in -- delayed gastric emptying time expected in

pregnancy, obesity, diabetics with autonomic pregnancy, obesity, diabetics with autonomic dysfunctiondysfunction

HistorHistoryy

Physical examinationPhysical examination

Vital signsVital signsAirwayAirwayHeartHeartLungsLungsExtremitiesExtremitiesNeurologic examinationNeurologic examination


Physical examinationPhysical examinationVital signsVital signsAirwayAirwayHeartHeartLungsLungsExtremitiesExtremitiesNeurologic examinationNeurologic examination


Physical examinationPhysical examination

Vital signsVital signsAirwayAirwayHeartHeartLungsLungsExtremitiesExtremitiesNeurologic examinationNeurologic examination


PREOPERATIVE TESTSMay be indicated for various purposes, including but not limited

to:

1)discovery or identification of a disease or disorder which may affect perioperative anesthetic care

2) verification or assessment of an already known disease, disorder, medical or alternative therapy

which may affect perioperative anesthetic care3) formulation of specific plans and alternatives for

perioperative anesthetic care.

Routine battery of laboratory tests vs

Problem directed, selective determination of laboratory tests

Routine Tests

A test ordered in the absence of a specific clinical indication or purpose

Indicated TestsA test that is ordered for a specific clinical indication or

purpose

ASA Practice Advisory for Preanesthesia Evaluation

A Report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation

PRACTICE ADVISORIESSystematically developed reports that are intended to

assist decision-making in areas of patient care where scientific evidence is insufficient to develop an evidence-based model

PRACTICE ADVISORIESIn contrast to STANDARDS or GUIDELINES,practice

advisories are not supported by sufficient numbers of controlled studies.

They may be adopted, modified or rejected according to clinical needs and constraints

ELECTROCARDIOGRAMECG abnormalities may be higher in older patients and in

patients with multiple cardiac risk factors

No consensus regarding a minimum age for obtaining a preanesthesia ECG

ELECTROCARDIOGRAMImportant clinical characteristics that may warrant

preop ECG: cardiocirculatory disease respiratory disease type or invasiveness of surgery

AMERICAN HEART ASSOCIATION/AMERICAN COLLEGE OF CARDIOLOGYGUIDELINES FOR ELECTROCARDIOGRAPHY: ECG abnormalities rise exponentially with age. Patients who have no apparent heart disease but are older

than 40 should have a preop ECG.

Preanesthesia Cardiac Evaluation Other than an ECGStress test, Echocardiogram, Radionucleotide imaging,

cardiac catheterization

Clinical characteristics to consider: cardiovascular risk factors type of surgery

Chest X-rayClinical chracteristics to consider: smoking recent URTI COPD cardiac disease

Preanesthesia Pulmonary Evaluation (other than X-ray)Pulmonary function tests, spirometry, pulse

oximetry, arterial blood gas

Clinical considerations: type and invasiveness of the sx procedure interval from prior evaluation treated or symptomatic asthma symptomatic COPD scoliosis with restrictive function

IS THERE AN OPTIMAL PREOPERATIVE Hb/Hct?10g/dl rule??? There are no randomized prospective studies defining a

specific minimum Hb conc as a risk factor for anesthesia and surgery.

Came from older, anecdotal case series andn cohort studies

Preanesthesia Hemoglobin and HematocritROUTINE Hb, Hct is not advisable

Clinical considerations: type and invasiveness of sx procedure liver disease extremes of age history of anemia, bleeding, other hematologic disorders

Clinical considerations for preop Hb determinationPatients with significant cardiac and pulmonary disease

will have a limited tolerance for perioperative anemia.

The decision for perioperative transfusion should be based on preop Hb conc, anticipated blood loss, and cardiorespiratory status

Preanesthesia Coagulation StudiesINR, PT, PTT, Platelets

Clinical considerations: bleeding disorders renal dysfunction liver dysfunction type and invasiveness of procedure

Routine coagulation tests prior to regional anesthesia?

The Task Force believes that there is not enough data to comment on the advisability of coagulation tests before regional anesthesia.

Preanesthesia Serum ChemistriesSerum electrolytes, glucose, renal and liver function

tests

Clinical considerations: perioperative therapies endocrine disorders risk of renal and liver dysfunction use of certain medications or alternative therapies

Preanesthesia UrinalysisIt is not indicated except for specific procedures (e.g. prosthesis implantation, urologic

procedures) and when urinary tract symptoms are present

Preanesthesia Pregnancy TestingBecause history and PE may be insufficient for

identification of early pregnancy, pregnancy testing must be OFFERED but not required for all females of childbearing age

SHOULD ALL ANTIHYPERTENSIVE AGENTS BE CONTINUED BEFORE SURGERY

BETA BLOCKERS and CLONIDINE: sequelae of abrupt discontinuation: withdrawal syndrome: rebound hpn advantage of continuation: cardiovascular risk reduction

recommendation: continue

SHOULD ALL ANTIHYPERTENSIVE AGENTS BE CONTINUED BEFORE SURGERYCalcium channel blockers: no withdrawal sequelae cardiovascular risk reduction perioperatively recommendation: continue

SHOULD ALL ANTIHYPERTENSIVE AGENTS BE CONTINUED BEFORE SURGERYACE inhibitors increased risk of intraoperative hypotension

recommendation: discontinue at least 10 hrs before anesthesia and surgery

Preoperative physical status classification Preoperative physical status classification of patients according to the American of patients according to the American

Society of AnesthesiologistsSociety of AnesthesiologistsClassClass DefinitionDefinition

11 A normal healthy patient.A normal healthy patient.

22A patient with mild systemic disease and no functional A patient with mild systemic disease and no functional limitations.limitations.

33A patient with moderate to severe systemic disease that results A patient with moderate to severe systemic disease that results in some function limitation.in some function limitation.

44A patient with severe systemic disease that is a constant threat A patient with severe systemic disease that is a constant threat to life and functionally incapacitating.to life and functionally incapacitating.

55A moribund patient who is not expected to survive 24 hours A moribund patient who is not expected to survive 24 hours with or without surgery.with or without surgery.

66 A brain-dead patient whose organs are being harvested.A brain-dead patient whose organs are being harvested.

EEIf the procedure is an emergency, the physical status is If the procedure is an emergency, the physical status is followed by “E” (e.g. “2E”)followed by “E” (e.g. “2E”)

ClassClass Mortality RateMortality Rate

11 0.06-0.08%

22 0.27-04%

33 1.8-4.3%

44 7.8-23%

55 9.4-51%

Preoperative physical status Preoperative physical status classification of patients according to the classification of patients according to the

American Society of AnesthesiologistsAmerican Society of Anesthesiologists

Informed Informed consentconsent

Preoperative visit culminates in giving the patient a Preoperative visit culminates in giving the patient a reasonable explanation of the options available for reasonable explanation of the options available for anesthetic managementanesthetic management

Informed consentInformed consent

written consent is advisable for written consent is advisable for medicolegal purposesmedicolegal purposes

any procedure any procedure performed without performed without patient’s consentpatient’s consent

physician liable physician liable for assault and for assault and batterybattery

How much of the risks How much of the risks should we tell?should we tell?

Only those that are Only those that are realistic risksrealistic risks in similar in similar patients with similar problemspatients with similar problems

It is advisable to inform the patient that some It is advisable to inform the patient that some complicationscomplications may be life threatening may be life threatening

The anesthetic planThe anesthetic planPremedicationPremedicationType of anesthesiaType of anesthesia

GeneralGeneralAirway managementAirway managementInductionInductionMaintenanceMaintenanceMuscle relaxationMuscle relaxation

Local or regional anesthesiaLocal or regional anesthesiaTechniqueTechniqueAgentsAgents

Monitored anesthesia careMonitored anesthesia careSupplemental oxygenSupplemental oxygenSedationSedation

Intraoperative managementIntraoperative managementMonitoringMonitoringPositioningPositioningFluid managementFluid managementSpecial techniquesSpecial techniques

Postoperative managementPostoperative managementPain controlPain controlIntensive careIntensive care

Postoperative ventilationPostoperative ventilationHemodynamic monitoringHemodynamic monitoring

Good day!Good day!

PREOPERATIVE EVALUATION

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