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JAFMC Bangladesh 2005, June; 1: 27-31 Rabiul et al… Pre-anaesthetic incidental detection of systemic diseases

PRE-ANAESTHETIC INCIDENTAL DETECTION OF


SYSTEMIC DISEASES
Rabiul M Alam1, Mahbubul M Alam2, Zahurul M Islam2

Abstract
Purpose: Pre-anaesthetic assessment provides the patients’ preoperative physical status, existing
medical conditions and their severity. Peri-operative morbidity and mortality are reduced by pre-
anaesthetic optimisation of the patients. This prospective study was aimed to find out the
incidence of detection of the pre-existing systemic diseases which were not diagnosed earlier.
Method: A total of 2,086 indoor patients were studied during pre-anaesthetic assessment who
were from all age-groups and of both sexes requiring routine surgical procedures under any type
of anaesthesia. Check-up was carried out basing on history, physical examinations and
investigation reports. The numbers of incidentally detected diseases were tabulated, analysed
and compared with that of those pre-existing diseases, prevailed in the population.
Result: The major incidental findings of diseases were: conduction heart block [18.75%], chronic
obstructive pulmonary disease (COPD) [15%], anaemia [11.62%], ischaemic heart disease (IHD)
[5.55%], and some other conditions like bronchial asthma, systemic hypertension, peptic ulcer
disease (PUD) and drug allergy. The findings were statistically significant (p<0.05) in respect
of conduction defects, COPD, anaemia, IHD, PUD and drug allergy.
Conclusions: The findings revealed a possibility of increased peri-operative morbidity and
mortality if meticulous and proper attention was not given while preparing the patients for
anaesthetic procedures. Thus it was concluded that every hospital must run an effective
anaesthesia out-patient department with the capability of careful and efficient check-up system to
detect the undiagnosed diseases during pre-anaesthetic assessment for safe anaesthesia.

Key words: pre-anaesthetic assessment, P/A checkup, incidental detection, systemic disease.

Introduction
Surgical mortality and morbidity are anaesthesia-related risks [1]. The
not only the consequences of the surgical preoperative anaesthetic visit also serves to
procedure itself, but also of the patient’s guide the most appropriate anaesthetic
preoperative physical status. The technique and to provide patient
preoperative anaesthetic visit is aimed information. Medical assessments enable
primarily at detecting these medical physicians to reduce morbidity by obtaining
conditions and assessing their severity. health status and planning peri-operative
Subsequent preoperative optimization of the management.
patient’s condition reduces perioperative and
1
Department of Anaesthesia, Combined Military Hospital, Chittagong, Bangladesh.
2
Department of Anaesthesia, Combined Military Hospital, Dhaka, Bangladesh.
Corresponding author: Dr. (Lt Col) Rabiul M Alam, MBBS, MCPS, FCPS; Department of Anaesthesia,
Combined Military Hospital, Chittagong cantonment, Chittagong, Bangladesh. E-mail: rabiuldr@gmail.com

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JAFMC Bangladesh 2005, June; 1: 27-31 Rabiul et al… Pre-anaesthetic incidental detection of systemic diseases

Peri-operative morbidity and mortal- endeavour were there to find out any
ity increase with the severity of pre-existing undiagnosed systemic disease.
diseases [2]. Preoperative evaluation is an
essential screening to ensure that the patient Results
is in the best possible physical condition Demographic data of all age group patients
before surgery [3]. During pre-anaesthetic are presented in Table 1. The total number
assessment, if proper attention is not of patients was 2,086, amongst which adults
ensured, there are chances to remain some predominated. Out of 2,086 patients 1,379
systemic diseases undetected. Failure to (66.1%) were adult, 493 (23.63%) were
undertake this activity may place the patient from paediatric age group and 214 (10.25%)
at increased risk of peri-operative morbidity were geriatric patients. Male were 55.6%
or mortality. and 44.4% were female. Table 2 shows the
proposed variety of surgical procedures,
Materials & methods amongst which laparotomy (16.34%) was
A total of 2,086 indoor patients predominant. Table 3 shows the numbers of
proposed for various type of routine surgical incidentally detected diseases, which were
procedures of all ASA classes and of both compared with that of those pre-existing
sexes were included in this prospective diseases. The incidental findings of diseases
study. With the approval of local ethical were: conduction heart block (18.75%),
committee the study was conducted in the COPD (15%), anaemia (11.62%), IHD
Anaesthesia OPD of a Combined Military (5.55%), bronchial asthma (1.61%), hyper-
Hospital in Bangladesh. Patients scheduled tension (1.3%), and some other conditions
to undergo any type of anaesthesia were like peptic ulcer disease and drug allergy.
included. Obtaining detailed history, The findings were statistically significant
performing relevant physical examinations, (p<0.05) in respect of conduction defects,
evaluating investigations results, enormous COPD, anaemia, IHD, PUD and drug
allergy.

Table 1: Demographic Data

Sex
Age No of case Percentage (%)
Male Female
Paediatric 493 23.65 368 125
Adult 1,379 66.10 675 704
Geriatric 214 10.25 117 97
Total 2,086 100 1,160 (55.6%) 926 (44.4%)

Note: Total no of patients was 2,086; in which adults predominated amongst the age groups.

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JAFMC Bangladesh 2005, June; 1: 27-31 Rabiul et al… Pre-anaesthetic incidental detection of systemic diseases

Table 2: Types of proposed surgical procedures

Proposed types of Surgery No of case Percentage (%)

Abdominal/Laparotomy 341 16.34


Gynaecological/Obstetric 156 7.47
Orthopaedic 124 5.94
Neurosurgical 45 2.15
ENT 245 11.34
Ophthalmological 320 15.34
Urological 277 13.27
Reconstructive 114 5.46
Others 464 22.24
Total 2,086 100

Note: Abdominal surgery was predominated among the types of proposed surgical procedures. Most of
the varieties of surgery were included in the study.

Table 3: Detected diseases


Pre-existing No of detected Percentage p-
Name of Diseases
diseases diseases (%) values
Heart block 16 3 18.75
COPD 20 3 15
<0.05
Anaemia 43 5 11.62
IHD 54 3 5.55
HTN 227 3 1.3 >0.05
PUD 5 16
<0.05
Hypersensitivity 1 6
Diabetes Mellitus 135 nil
Congenital heart disease 11 nil
-
Valvular heart disease 3 nil
-
CRF 10 nil
CVA 5 nil
Thalassaemia 4 nil

Note: Peptic ulcer disease and hypersensitivity were detected more than they were
diagnosed earlier and highly significant.

Discussion
Preoperative medical assessment 1960s. Then, laboratory tests were included
relied primarily on accurate history-taking in late 1960s, which can aid in optimizing a
and physical examination from 1940 to patient’s preoperative condition once a

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JAFMC Bangladesh 2005, June; 1: 27-31 Rabiul et al… Pre-anaesthetic incidental detection of systemic diseases

disease is suspected or diagnosed. But it has to and read by the anaesthetist. Patients
several shortcomings like failure to uncover likely to present anaesthetic problems
real pathological condition; the detected should have been previously identified and
abnormalities do not necessarily affect seen by an anaesthetist prior to being
patient care or outcome and their scheduled for surgery. This is often done on
inefficiency in screening for asymptomatic an ad hoc basis but it is more efficiently
diseases [4]. Practically, most abnormalities carried out in an anaesthetic pre-operative
are discovered on preoperative assessment assessment clinic [8]. Identification of
or even on admission screening for non- potential problems during pre-anaesthetic
surgical purposes. A conclusion was drawn assessment relies upon the knowledge,
from a long series of epidemiologic studies sincerity and commitment of the assessors,
and controlled trials that preoperative often augmented by following the screening
assessment should be used primarily to protocols developed by the anaesthesia
ensure the optimal preoperative condition of department. When a patient is in a special
a patient who has not received healthcare risk, should be referred to an appropriate
recently [5]. Studies showed that the history specialist.
and physical examination are the best Guidelines may be provided by the
measures of screening for diseases [6]. anaesthesia department for the surgical team
There are at least three methods for to ensure that appropriate investigations are
organising preoperative evaluation undertaken and suitable actions taken if
efficiently. First, the surgeon, internist, problems are identified. The fundamental
family practitioner, or anaesthesiologist who process of taking a detail history and
sees the patient before a scheduled performing a systemic clinical examination
procedure can obtain the history and per- remains the foundation of preoperative
form the physical examination. Second, a assessment. There are many surgical
clinic can be set up in an outpatient facility conditions which have systemic effects, like
to perform these two tasks early enough to bowel cancer may be associated with
ensure that laboratory tests or consultations malnourishment, anaemia and electrolyte
can be obtained without delaying schedules. imbalance etc. These scenarios must be
Third, a questionnaire answered by the sought and quantified properly. The
patients can be used to indicate likely presence of coexisting medical diseases
disease processes and appropriate laboratory must also be identified together with the
tests [7]. At present in our set-up, an extent of any associated limitations to nor-
anaesthesia OPD is on operation to evaluate mal activity. In our study it is revealed that
the cases preoperatively. many systemic diseases like conduction
With previously screened healthy heart block, COPD, anaemia, IHD,
patients, the anaesthetist, on the day of bronchial asthma, hypertension, and some
surgery, must check the results of screening other conditions such as peptic ulcer disease
and of other pre-operative testing. Any tests and drug allergies may remain undiagnosed
performed pre-operatively must be available even during indoor health care, which have a

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JAFMC Bangladesh 2005, June; 1: 27-31 Rabiul et al… Pre-anaesthetic incidental detection of systemic diseases

significant impact on the course and continuum of medical care to which a


outcome of anaesthesia and thereby on sur- primary care physician, an internist, an
gery. This work also alarms us to be more anaesthesiologist, and a surgeon contributes.
meticulous and curious during pre- The interns and resident physicians placed in
anaesthetic assessment. The indoor indoor setup should show their keen interest
physicians of surgical patients should take in this respect and they have effective role to
responsibilities to treat the ‘whole patient’. prepare the patients scheduled for surgery
These conditions must be detected and appropriately. A post-surgical satisfied
optimised appropriately before hand in all patient is obviously an outcome of
routine cases to ensure a safe anaesthesia, to multidisciplinary contribution. The trends of
reduce morbidity and for satisfactory patient motivating the undergraduate clinical
care service. students regarding these essential aspects
should be more intensified. Detection of any
Conclusion coexisting systemic disease and subsequent
The importance of integrated necessary preoperative optimization not
practice in medical care is increasing day by only aids the anaesthetic management but
day. A medical history can be provided by a also saves the surgical team from any fatal
number of sources because patients outcome.
undergoing surgery move through a

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