ANESTHESIOLOGY

EXIMIUS
PREOPERATIVE EVALUATION
JOHDIE JESS MELODY ALCONCHER, M.D., DPBA OCTOBER 2018 2021
PREOPERATIVE EVALUATION o Present Illness (age, sex, problem, planned

o Initial step in the preparation of a patient for the operation

procedure (elective, emergency)
1
o Past Medical History (Medications, Allergies,
o Consists of a review of previous medical records, survey Past Surgical History, Family History, Social
of past and present medical and surgical problems, and a History, )
well-directed physical examination. o Review of Systems
o Laboratory tests augment the findings of the History and
 General: exercise tolerance, weakness,
physical examination.
fatigue, fever, weight change
o Develops a plan for anesthesia and perioperative
 Skin: rashes, sores, lesions
management and discuss it with the patient.
 Head: frequent headaches
o Establishes a doctor-patient relationship.
 Eyes: double, blurred, loss of vision,
o Reduces patient anxiety by building a foundation of trust
glaucoma, cataracts
and respect.
 Ears: limited hearing, tinnitus, vertigo,
o Screening tool to anticipate and avoid airway difficulties or
discharge, pain
problems with anesthetic drugs.
 Nose and Throat: sinusitis, sore throat,
o Previous anesthesia records should be reviewed.
epistaxis, dysphagia
o Review of the patient‟s allergies (latex allergy, potential
 Mouth: lesions, bleeding gums,
drug interaction) and medication list.
dentures, loose or damaged teeth
o Evaluation should be:
 Cardiac: angina, palpitations, dyspnea,
 Complete allow the info to be relayed
orthopnea, peripheral edema
 Accurate to others medico legal
 Respiratory: cough, sputum, hemoptysis
 Clear purposes.
 GI: heartburn, nausea, vomiting,
diarrhea, constipation, hematemesis,
TASK
melena, jaundice
o To have the patient in the best possible condition, both
 Urinary: frequency, urgency, nocturia,
mental, physical prior to operation with the ultimate goal of
dysuria, hematuria, incontinence
reduced perioperative morbidity and mortality.
 Female: LMP (likelihood of pregnancy)
 Extremities: claudiation, joint pain, back
GOALS OF PREOPERATIVE EVALUATION
pain
o Review database
 Neurologic: seizure, syncope,
 Medical history
numbeness, loss of consciousness
 Consultations
 Hematologic: easy bruising, bleeding,
 Laboratory and Diagnostic Studies
past transfusion
o Perform PE directed at anesthetic concerns
 Endocrine: thyroid, diabetes
o Develop anesthetic plan
 Psychiatric: emotional illness
o Establishing good physician-patient relationship
o Pulmonary system
o Reduce patient risk and morbidity associated with surgery
 Tobacco use
and coexisting diseases
 Dyspnea
o Lessen the anxiety of the patient
 Exercise tolerance
o Promote efficiency and reduce costs
 Cough
o Prepare the patient medically and psychologically for
 Wheezing
surgery and anesthesia
 Inhaler use
o Obtain informed consent
 Recent URTI
o All patients receive a preoperative anesthetic evaluation
 Snoring or sleep apnea
o elective should be evaluated a day prior to operation
o Cardiovascular system
o emergency cases should be seen prior to operation
 Uncontrolled hypertension
 Unstable cardiac disease
PREOPERATIVE VISIT
 Angina
I. Problem Identification
 Dyspnea
II. Risk Assessment
 Syncope
III. Preoperative Preparation
IV. Plan of Anesthetic Technique  Undergone coronary artery stent or
cardiac implantable device placement
I. PROBLEM IDENTIFICATION o Neurologic System
o Through:  Seizure history
 History  Preexisting neuromuscular disease or
 Physical examination nerve injuries
 Laboratory investigation  History of cerebrovascular disease

HISTORY PHYSICAL EXAMINATION

o Do not replicate those of the admitting o General Examination
physician o Pulmonary System
o Goal: discover and assess any abnormalities  Respiratory rate
that may affect the perioperative course and  Chest expansion
the plan for anesthesia.  Nail color

TRANSCRIBERS Group 11 EDITOR Arnedo, Chuck Davis D. 1 of 7

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 Patient‟s ability to carry on a MEASUREMENTS

conversation or to walk without dyspnea
 Auscultation
o Cardiovascular system
 Blood pressure evaluation
 Auscultation
 Presence of peripheral pulses
o Should focus on evaluation of:
 Upper airway
 Respiratory system
 Cardiovascular system
3 Fingers Mouth Opening
3 Fingers hypomental Distance
2 Fingers between the thyroid notch and the floor of the
mandible
1 Finger Lower Jaw Anterior sublaxation
MOVEMENT OF THE NECK

Why would this man’s airway be difficult to manage?

MALFORMATION
1) SKULL

o Predictors of difficult intubation

 Mallampati
 Measurements
 Movement of the Neck
 Malformations of the skull, teeth,
obstruction and pathology
2) TEETH
MALLAMPATI
Class I

Class II

Class III

Class IV

TRANSCRIBERS Group 11 EDITOR Arnedo, Chuck Davis D. 2 of 7

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3) OBSTRUCTION pulmonary conjunction with other

emboli anticoagulant and
 Prevent antithrombotic drugs
atherosclerosis
 Promote wound
healing

LABORATORY TESTING
o Indicated for
- Discovery or identification of a disease or
disorder which may affect perioperative
4) PATHOLOGY anesthetic care
- Verification or assessment of an already known
disease, disorder
- Formulation of specific plans and alternatives for
perioperative anesthetic care
o Recommended Laboratory Testing
 Blood Count:
 Neonates
 Physiologic age >75
 Malignancy
 Renal disease
 Anticoagulant use
o Other factors to consider during intubation:  Bleeding/hematologic disorder
 Long upper incisors  Class C procedure
 A prominent “overbite”  Coagulation Studies:
 The patient cannot protrude the mandibular  Chemotherapy
incisors anterior to maxillary incisors  Hepatic disease
 Interincisor distance is less than 3cm when  Bleeding disorders
mouth is fully opened  Anticoagulants
 Uvula is not visible when tongue is protruded  Electrolytes:
with patient in sitting position  Renal disease
 Shape of palate is highly arched or very narrow  Diabetes
 Mandibular space is non-compliant  Diuretic, digoxin, or steroid use
 Thyromental distance is less than 3  CNS disease
fingerbreadths  Endocrine disease
 Neck is short or thick  BUN/Creatinine:
 Patient lacks normal range of motion of head  Physiologic age > 75
and neck  CVD
o Medications:  Renal disease
 Diabetes
Name Uses Effects/interactions  Diuretic
Garlic  Inhibition of Potential for increased  CNS disease
platelet bleeding  Class C procedure
aggregation  Blood glucose
 Lipid lowering  Physiologic age > 75
 BP lowering  Diabetic
 Antioxidant  Steroid use
Ginger  Antinausea Potent inhibitor of  CNS disease
 Antispasmodic thromboxane  Class C procedure
synthetase  Liver Function Test:
May increase bleeding  Hepatic disease
time  Hepatitis exposure
Ginkgo  Blood thinner May enhance bleeding
 Malnutrition
in patients on
anticoagulant or  Chest X-ray:
antithrombotic therapy  CVD
Ginseng  Energy level May inhibit platelet  COPD
enhancer aggregation and  Malignancy
 Antioxidant increase bleeding  Pregnancy Test:
Vitamin E  Slow aging May increase bleeding  Positive pregnancy
 Prevent stroke, particularly in

TRANSCRIBERS Group 11 EDITOR Arnedo, Chuck Davis D. 3 of 7

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 ECG:
 Physiologic age > 75
 CVD
 Pulmonary disease
 Diabetes
 Digoxin use
 CNS disease
 Class C procedure
 Albumin:
 Physiologic age > 75
 Malnutrition
 Class C procedure
 Type and Screen:
 Physiologic age > 75
 Hematologic disorder
 Coagulation abnormality
 Class C procedure
II. RISK ASSESSMENT
 Intermediate (Reported risk <5%)
o Components for evaluating perioperative risk:
 Carotid endarterectomy
 patient's medical condition preoperatively
 Head and neck surgery
 extent of the surgical procedure
 Intraperitoneal and intrathoracic
 risk from the anesthetic
procedures
o ASA Physical Status Classification System
 Orthopedic surgery
 Prostate surgery

o Goldman Cardiac risk index  Low (Reported risk <1%)

 History of IHD  Endoscopic procedures
 History of CHF  Superficial procedures
 History of CVD  Cataract surgery
 Preoperative treatment with insulin  Breast surgery
 Preoperative serum crea > 2.0mg/dl
 High risk type of surgery
o Risks for Surgical Procedure
 Cardiac Risk Stratification Based on the
Surgical Procedure in Patients with known
Coronary Disease
 High (Reported risk >5%)
 Emergent major operations,
particularly in elderly
 Aortic and other major vascular
surgery
 Surgical procedures associated with
large fluid shifts and/or blood loss

TRANSCRIBERS Group 11 EDITOR Arnedo, Chuck Davis D. 4 of 7

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o Patient Risk Factors: OTHERS:

 Clinical Predictors of Increased Perioperative  Obesity
Cardiovascular Risk  Pediatric patients
 MAJOR:  Geriatric patients
 Unstable coronary syndromes III. PREOPERATIVE PREPARATION
- Acute (<7d) or recent MI (<1mo) o Fasting Recommendations
with evidence of ischemic risk
- Unstable or severe angina
 Decompensated heart failure
 Significant arrhythmias
- High-grade AV block
- Symptomatic ventricular
arrhythmia
- SVT uncontrolled rate
 Severe valvular disease
 INTERMEDIATE:
 Mild angina pectoris
 Previous myocardial infarction by
history or pathological Q waves
 Compensated or prior heart failure
 Diabetes mellitus
 Renal insufficiency o Anesthetic indications:
 MINOR:  Anxiolysis, sedation, and amnesia
 Advanced age (Benzodiazepine (diazepam, lorazepam)
 Abnormal ECG (LVH, LBBB, ST-T  Analgesia (Narcotics)
abnormalities)  Drying of airway secretions (Atropine,
 Rhythm other than sinus (e.g. a fib) glycopyrrolate, scopolamine)
 Low functional capacity (e.g. inability  Reduction of anesthetic requirements,
to climb one flight of stairs with a Facilitation of smooth induction
bag of groceries)  Patients at risk for GE reflux (Ranitidine,
 History of stroke metoclopramide, sodium citrate)
 Uncontrolled systemic hypertension o Surgical indications:
 Poor exercise capacity  Antibiotic prophylaxis for infective endocarditis
- < four level blocks or two flights o Co-existing Disease indications:
of stairs  Some medications should be continued on the
day of surgery (Blockers, thyroxine)
1 MET  Others are stopped on the day of surgery (Oral
• Can you take care of yourself? hypoglycemic, anti-depressants)
• Eat, dress, or use the toilet  Steroids within the last six months may require
• Walk indoors around the house?
supplemental steroids
• Walk a block or two on level ground at 2-3 mph or
o Common Preoperative Medications, Doses, and
3.2-4.8 km/hr
• Do light work around the house, like dusting or Administration Routes
washing dishes?

4 METs
• Climb a flight of stairs or walk up a hill?
• Walk on level ground at 4 mph or 6.4 km/hr?
• Run a short distance?
• Do heavy work around the house, like scrubbing
floors or lifting or moving heavy furniture?
• Participate in moderate recreational activities like
golf, bowling, dancing, double tennis, or throwing a
baseball or football?

> 10 METs
• Participate in strenuous activities like swimming,
singles tennis, football, basketball or skiing

 Tobacco use
 Bronchial Asthma/COPD
 Obstructive sleep apnea

TRANSCRIBERS Group 11 EDITOR Arnedo, Chuck Davis D. 5 of 7


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PREOPERATIVE EVALUATION
o Pre-emptive Anesthesia
 “protective premedication”
 Analgesia before the injury or surgical stimulus
 Use of opiates, NSAIDs, local anesthetics,
adjuvants
 Introduced to protect the CNS from deleterious
effects of noxious stimulus
 Protect patient from the resulting hyperalgesia
and allodynia
o Anti-sialagogue as premedication
 (eg. glycopyrolate) given IM or IV are rarely
needed but may be indicated for awake fiber
optic intubation or before ketamine anesthesia
 Results
 2% of unpremedicated patients
experienced problems with secretions of
a degree sufficient to require treatment
 This small percentage appears
insufficient to warrant routine
preoperative anticholinergic medication
 Pediatrics
 Sympathetic components not fully
developed until 4 to 6 months
 Immature baroreceptors
 Atropine reduces the incidence of
hypotension during induction in
neonates and infant less than 3 months
 Warranted to give
 Atropine 20 ug/kg should be given
preoperatively or preferably IV at
induction of anesthesia to prevent reflex
bradycardia
- Laryngoscopy, tracheal
intubation
- Tracheal suctioning
- Traction on eye muscle and
the viscera
Recommendations for GIT Stimulants
o The routine preoperative use of GIT
stimulants to decrease the risk of
pulmonary aspiration in patients who have
no apparent increased risk for pulmonary
aspiration is NOT RECOMMENDED
o Preoperative Pharmacologic Blockade of Gastric Acid
Secretion
 Histamine 2 receptor antagonist
 Meta-analysis of double blind randomized
placebo-controlled trials support the efficacy of
cimetidine to reduce gastric volume (6 studies)
and acidity during the perioperative period (7
studies)
 Randomized placebo-controlled trials indicate
that famotidine is effective in reducing gastric
acid volume and acidity (3 studies)
 Proton pump inhibitors
 Randomized controlled trials support
the efficacy of omeprazole in reducing
gastric volume and acidity (4 studies)
 With similar findings reported for
lansoprazole (4 studies)
TRANSCRIBERS Group 11 EDITOR
EXIMIUS
2021
Recommendations for preoperative pharmacologic
blockade of gastric acid secretion
o The routine preoperative use of
medications that block gastric acid
secretion to decrease the risk of pulmonary
aspiration in patients who have no
apparent increased risk for pulmonary
aspiration is NOT RECOMMENDED
o Preoperative antacids
 Randomized controlled trials
 Preoperative antacids (eg, sodium
citrate, magesium trisilicate) increase
gastric pH during perioperative period (5
studies)
 Equivocal findings regarding gastric
volume
Recommendations for preoperative antacids
o The routine preoperative use of antacids to
decrease the risk of pulmonary aspiration
in patients who have no apparent
increased risk of pulmonary aspiration is
NOT RECOMMENDED
o Only non-particulate antacids
 Should be used when antacids
are indicated for selected patients
for purposes other than reducing
the risk of pulmonary aspiration
o Preoperative Anti-emetics
 Randomized controlled trials indicate that the
preoperative administration of droperidol (3
studies)and ondansetron (3 studies)are effective
in reducing nausea and vomiting during the
period after surgery
Recommendation preoperative antiemetics
o The routine preoperative use of antiemetics
to reduce the risks of pulmonary aspiration
in patients who have no apparent
increased risk for pulmonary aspiration is
NOT RECOMMENDED
IV. PLAN FOR ANESTHETIC TEACHNIQUE
1. Local or Regional anesthesia with „standby„monitoring
with or without sedation.
2. General anesthesia; with or without intubation.
Spontaneous or controlled ventilation is used.
3. Combined regional with general anesthesia.
SUMMARY
o History and physical most important assessors of disease
and risk
o ASA and functional status good predictors of risk
o Lab tests have some usefulness
• add little in low risk patients
• may add false + ves
• add expense
o Preoperative evaluation is necessary to stratify risk to the
patient
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o The evaluation delineates patient clinical factors as well

as extent of surgery
o The patient, surgeon, anesthesiologist are aware of the
perioperative risk and may plan therapy accordingly

TRANSCRIBERS Group 11 EDITOR Arnedo, Chuck Davis D. 7 of 7