Pre-Operative Evaluation

Yrah Damiene Fernandez

Clinical Clerk
Department of Anesthesia
March 2016
 Pre-operative Evaluation
process of clinical assessment that
precedes the delivery of anesthesia care
done by anesthesiologist
consists medical records, interview,
physical examination, and findings from
medical tests and evaluations.
 Pre-operative Evaluation
educate the patient
organize resources for perioperative care
formulate plans for intraoperative care,
postoperative recovery, and perioperative
pain management
 Pre-operative Evaluation
Required by the Joint Commission for the
Accreditation of Healthcare Organizations
(JCAHO)
Practice Advisory for Pre-Anesthesia Evaluation
developed by the American Society of
Anesthesiologists (ASA) - are systematically
developed reports that are intended to assist
decision-making in areas of patient care.
 Preoperative Evaluation
The initial step in the preparation of a
patient for the operating room
Done at least 24 hours before scheduled
surgery
 Objectives of Pre-operative
Evaluation
To review database (know the history)
To perform a physical exam
To establish a doctor-patient relationship
To obtain consent (for anesthesia)
To make an anesthesia plan
 Pre-operative Evaluation
Three aspects of acute history
1. History of present illness
2. Exercise tolerance
3. Patients visits to his physician

Three aspects of chronic history

1. Medications
2. Social history
3. Past medical & family history

Three aspects of physical examination

1. Airway
2. Cardiovascular
3. Pulmonary
 OBJECTIVE 1:
TO REVIEW DATABASE
 Pre-operative History Taking
Goals:
Inform the patient of the risk
Educate the patient regarding the anesthesia and events to
take place in the pre, peri-, an post operative period
Answer questions and reassure the patient and family
Notify NPO status
Instruct the patient about which medications to take on the
day of surgery or which medications to stop taking
Final: use the operative experience to motivate patient to
more optimal heath and improved health outcomes
 Medical History
HPI
Past Medical History
o Medications
o Allergies
o Previous Surgical and Anesthetic History
Family History
o Malignant hyperthermia
o Pseudocholinesterase abn
o G6PD Deficiency
 Medications
Medication Anesthetic Implication
Aspirin Platelet dysfunction & bleeding
potential
Aminoglycosides Can potentiate
nondepolarizing relaxants
Insulin Hypoglycemia if not monitored
Lithium Potentiate neuromuscular
blockers
Monoamine Oxidase Inhibitors Increased catecholamine
stores
Warfarin Excessive intraoperative
bleeding
 Pulmonary
Tobacco use
Shortness of breath, cough, wheezing, stridor, and
snoring or sleep apnea
Asthma
Obstructive Sleep Apnea (OSA)
URTI (presence and recent history)
 Cardiovascular
Uncontrolled hypertension
Unstable cardiac disease
Congestive heart failure
Valvular heart disease (aortic stenosis, mitral valve
prolapse)
Cardiac dysrhythmias
 Neurologic System
ensures a normal mental status
 Endocrine System
Diabetes mellitus
increased risk of developing CAD, perioperative MI,
hypertension, and congestive heart failure
exogenous insulin to ketoacidosis
Delayed elective if suboptimal blood glucose control (hemoglobin A1c >6% to 8%,
abnormal electrolytes, ketonuria)
Administration of perioperative beta-blockers
 OBJECTIVE 2:
TO PERFORM A PHYSICAL
EXAMINATION
 PHYSICAL EXAMINATION
The most important parts of the pre-anesthetic
physical exam are:
1. Airway
2. Cardiovascular
3. Pulmonary
4. Neurologic
 PHYSICAL EXAMINATION
Vital Signs
Head and Neck
Cardiovascular system
Pulmonary system
Back (check the spine)
Neurologic Examination
 Vital Sign
Height and weight
o dosage of anesthetic drugs are weight based
Blood pressure measurement
Resting pulse
Respiration
Pain scoring if the patient is in pain
Mouth and Oral cavity
o Extent of symmetry of mouth opening
o Health of the teeth
loose tooth/teeth that predisposes the patient to aspiration
or airway obstruction
o Presence of dental appliances
o Size of the tongue
Larger in pediatric patients than in adults
o Palate
Mouth and Oral cavity
Size of the mandible
Temporomandibular joint (TMJ) function
Thyromental distance
Prior surgeries, neck masses or tracheal deviations
Range of motion of the head and neck
 Airway Examination
Always the basic concern of the anesthesiologist
Difficult or failed airway management is the major
factor in anesthesia-related morbidity
The ability to review previous anesthetic records is
especially useful in uncovering unsuspected difficult
airways or to confirm previous uneventful
intubations, assuming the patient's body habitus has
not changed in the interim.
 MALLAMPATI CLASSIFICATION
Direct Visualization, Laryngoscopic
Class
Patient Seated View
soft palate, fauces,
I uvula, pillars
Entire glottic

soft palate, fauces, Posterior

II uvula commissure
Soft palate, uvular Tip of
III base epiglottis
No glottal
IV Hard palate only
sturctures
Modified Cormack-Lehane Score (MCLS)
Direct Visualization, Laryngoscopi
Class
Patient Seated c View

soft palate, fauces,

I uvula, pillars
Entire glottis

soft palate, fauces, Posterior

II uvula commissure

Soft palate, uvular Tip of

III base epiglottis

No glottal
IV Hard palate only
sturctures
Components of the Pre-Op Airway PE
Airway Examination Component
Length of upper incisors
Relation of maxillary and
mandibular incisors during
normal jaw closure
Relation of maxillary and
mandibular incisors during
voluntary protrusion of
mandible
Interincisor distance
Visibility of uvula
Nonreassuring Findings
Relatively long
Prominent overbite (maxillary
incisors anterior to the
mandibular incisors)
Patient cannot bring
mandibular incisors anterior to
maxillary incisors
<3 cm
Not visible when the tongue is
protruded with the patient in the
sitting position
Components of the Pre-Op Airway PE
Airway Examination
Component
Shape of palate
Compliance of mandibular space
Thyromental distance
Length of neck
Thickness of neck
Range of motion of head and
neck
Nonreassuring Findings
Highly arched or very narrow
Stiff, indurated, occupied by a
mass, or nonresilient
<3 fingerbreadths
Short neck
Thick neck
Patient cannot touch the tip of
the chin to the chest or is
unable to extend the neck
 FINDINGS ASSOCIATED WITH POSSIBLE
DIFFICULT AIRWAY

Mallampati classification of 2
Thyromental space of 3 fingerbreadths
Diminished neck extension
Large tongue
Overbite
Narrow-high arched palate
Decreased TMJ mobility
Short thick neck
 Physical Examination
Pulmonary System
Inspection (respiratory rate, symmetry,
deformities, use of accessory muscles, nail
color, ability to carry on a conversation,
pattern of breathing)
Palpation (chest retractions, chest expansion)
Percussion
Auscultation (breath sounds, adventitious
sounds)
 Physical Examination
Cardiovascular system
Inspection (precordium, veins as access sites,
peripheral edema)
Palpation (point of maximal impulse, thrills,
peripheral pulses)
Percussion
Auscultation of the heart (heart rate, rhythm,
murmur, systemic blood pressure)
 Preoperative Laboratory Tests
Need not ordered
Frequently fails to uncover pathologic
conditions
Inefficient in screening for abnormalities in
asymptomatic patients
 Routine Pre-Operative Laboratory Evaluation

Hemoglobin or Hematocrit
all menstruating women
all patients over 60 years old
all patients likely to experience significant blood loss and
may require transfusion
Serum Glucose & Creatinine
all patients over 60 years old
diabetic patients
specific clinical indications
 Routine Pre-Operative Laboratory Evaluation
Electrocardiogram (ECG)
all patients over 40 years old
all patients with specific indications hypertension,
palpitations, previous MI

Chest Radiograph
all patients over 60 years old
specific clinical indications hypertension, malignancy, acute
pulmonary symptoms
 Recommendations for Preoperative Resting 12-
Lead Electrocardiogram (ECG)
Class I
(Procedure is indicated)
1.Pre-operative resting 12-lead ECG is recommended for patients
with at least one clinical risk factor who are undergoing vascular
surgical procedures
1.Pre-operative resting 12-lead ECG is recommended for patients
with known CHD, peripheral arterial disease, or cerebrovascular
disease who are undergoing intermediate-risk surgical
procedures
Class IIa
(Procedure is reasonable to perform)
1.Pre-operative resting 12-lead ECG is reasonable in persons with
 Recommendations for Preoperative Resting 12-
Lead Electrocardiogram (ECG)

Class IIb
(Procedure may be considered)
1.Pre-operative resting 12-lead ECG may be reasonable in
patients with at least 1 clinical risk factor who are
undergoing intermediate-risk operative procedures.
Class III
(Procedure should NOT be performed because it is not helpful)
1.Preoperative and postoperative resting 12-lead ECGs are
not indicated in asymptomatic persons undergoing low-risk
surgical procedures.
 PATIENT-SPECIFIC BASELINE TESTING BEFORE
ANESTHESIA
Tests
Albumin
B-hCG Possible pregnancy
CBC w/ platelet Alcohol abuse; Anemia; Cardiovascular, Intracranial, Pulmonary, or Renal disease; Malignancy;
Malnutrition; Personal or Family history of bleeding; Poor exercise tolerance; Radiation therapy;
Rheumatoid arthritis; Sleep apnea; Smoking >40 pk-yr; Anticoagulant use; Procedures with
significant blood loss or High-risk category

Creatinine Cardiovascular, Hepatic, Intracranial, Peripheral vascular or Renal

disease; Diabetes; Morbid obesity; Poor exercise tolerance; Systemic lupus; Use of Digoxin,
Diuretics, Steroids; Procedures with Radiographic dye

CXR Only for active, acute symptoms especially with: Cardiovascular or

Pulmonary disease; Rheumatoid arthritis; Smoking >40 pk-yr; Systemic lupus;
Radiation therapy to the chest or thorax
 PATIENT-SPECIFIC BASELINE TESTING BEFORE
ANESTHESIA
Tests
ECG Alcohol abuse; Cardiovascular, Cerebrovascular, Intracranial, Peripheral vascular, Pulmonary, or Renal
disease; Diabetes; Morbid Obesity; Poor exercise
tolerance; Rheumatoid arthritis; Sleep apnea; Smoking >40 pk-yr; Systemic
lupus; Radiation therapy to chest or breasts; Use of Digoxin
Electrolytes Cerebrovascular, Intracranial, or Renal disease; Diabetes; Malnutrition; Use of Digoxin, Diuretics, or
Steroids; High-risk procedure
Glucose Cerebrovascular, or Intracranial disease; Diabetes; Morbid obesity; Poor exercise tolerance; Steroid use

Liver Function Alcohol abuse, Exposure to Hepatitis, Liver Disease

PT Alcohol abuse; Hepatic disease; Malnutrition; Personal or Family history of bleeding; Use of Warfarin

PTT Personal or Family history of bleeding or hypercoagulability; Use of unfractionated Heparin

TSH, T3, T4 Thyroid disease; Use of Thyroid medications

Urinalysis Suspected Urinary tract infection
 ASA Physical Status Classification
ASA
Class
Disease State Examples MR

1 Healthy patient without organic, biochemical, or psychiatric disease. 0.06-0.08%

2 Mild to moderate systemic disturbance that may not be related to the reason for Mild asthma; Well-controlled
hypertension; pregnancy
surgery. No significant impact on daily activity. Unlikely impact on anesthesia and 0.27 - 0.4%
surgery.
3 Severe systemic disturbance that may or may not be related to the reason for RF on dialysis;
surgery. Limits normal activity. Significant impact on daily acitivity. Likely impact on Class 2 CHF 1.8 - 4.3%
anesthesia and surgery
4 Severe systemic disturbance that is life threatening with or without surgery. Acute MI;
RF requiring MV
Requires intensive therapy. Serious limitation of daily activity. Major impact on 7.8 - 23%
anesthesia and surgery.
5 Moribund patient who has little chance of survival but is submitted to surgery as a
last resort (resuscitative effort).
9.4 - 51%
A moribund patient who is not expected to survive 24 hours with or without surgery.
E = Emergency

6 A brain-dead patient whose organs are being harvested)

E Indicates emergency surgery

ASA CLASSIFICATION FOR PERI-OPERATIVE
MORTALITY RATE

Clas Mortality rate

s
1 0.06 0.08%
2 0.27 0.40%
3 1.80 4.30%
4 7.80 23%
5 9.40 51%
 OBJECTIVE 3:
TO ESTABLISH DOCTOR-
PATIENT RELATIONSHIP
 Anesthesiologist-Patient Relationship
Organized interview
Reassuring the patient
Events of the perioperative period:
NPO status
Estimated time of surgery
Need for pre-medications
Post-operative recovery
Plans for post-operative pain control
 OBJECTIVE 4:
TO OBTAIN CONSENT
 Informed Consent
Anesthetic plan
Alternatives
Potential complications
 OBJECTIVE 5:
TO MAKE ANESTHESIA PLAN
 Anesthesia Plan
NPO status
Anesthesia techniques
Pre-medications
Post-operative recovery
Post-operative pain control
 PRE-OPERATIVE NOTHING BY
MOUTH (NPO) ORDERS
Guidelines for NPO status

Age Solids Clear liquids

<6 mos. 4 2
6 - 36 mos. 6 3
3 - 6 yr. 8 3

6 years or older:
NPO after midnight or at least 8 hours
prior to arrival time.
 FACTORS ASSOCIATED WITH INCREASED RISK
FOR ASPIRATION

Recent food intake- stomach will be distended

Elderly patient- slowed gastric emptying
Decreased consciousness
Increased intragastric pressure- obstruction
Increased acid production
Gastric and intestinal hypomotility
 FACTORS ASSOCIATED WITH INCREASED RISK
FOR ASPIRATION
Impaired esophageal sphincter control
Neuromuscular incoordination

Presence of NGT- will keep gastroesophageal sphincter patent

Pregnancy-

considered to have a full stomach because of the

anatomical and physiologic changes in pregnancy
there is lessening of the curvature and flattening of the
pyloric area
due to the hormone progesterone
 Guidelines for Food and Fluid Intake
Before Elective Surgery
Fasting Recommendations to Reduce Risk of Aspiration
Ingested Material Minimum Fasting
Period
(All Ages)
Clear liquids (water, pulp-free juices, 2 hours
carbonated beverages, clear tea, black coffee)

Breast milk 4 hours

Infant formula 6 hours
Non-human milk 6 hours
Light meal (toast and clear liquids; meals that 6 hours
include fried or fatty foods or meat may
prolong the gastric emptying time)
 Risk Factors for Postoperative Pulmonary
Complications
Potential Patient-Related Risk Factor
Advanced Age
ASA class II
CHF
Functionality Dependent
COPD
Weight loss
Impaired sensorium
Cigarette use
Alcohol use
Abnormal findings on chest examinations
Diabetes
Obesity
Asthma
Obstructive sleep apnea
Corticosteroid use
HIV Infection
Arrhythmia
Poor exercise capacity
 Risk Factors for Postoperative Pulmonary
Complications
Potential Procedure-Related Risk Factor
Aortic aneurysm repair
Thoracic surgery
Abdominal surgery
Upper abdominal surgery
Neurosurgery
Prolonged surgery
Head and neck surgery
Emergency surgery
Vascular surgery
General anesthesia
Anesthesia Techniques
General Anesthesia
Inhalational
TIVA
Regional Anesthesia
Epidural anesthesia
Sub-arachnoid block
Caudal anesthesia
Peripheral Nerve Block
 Anesthesia Technique Considerations
Coexisting diseases
Site of surgery
Position of the patient
Risk of aspiration
Age of the patient
Patient cooperation
Anticipated ease of airway management
Coagulation status
Previous response to anesthesia
Preference of the patient
 PRE-OPERATIVE MEDICATION
Psychological Preparation
Pharmacologic Preparation
Primary Goals of Pharmacologic Premedication

1. Relief of anxiety
2. Sedation
3. Amnesia
4. Analgesia
5. Prevention of airway secretion
6. Prevention of autonomic reflex responses-
hypertension, tachycardia
7. Reduction of gastric fluid volume
8. Increase in gastric fluid pH
9. Reduction of anesthetic requirements
 Secondary Goals of Pharmacologic
Premedication
1. Decrease vagal activity
2. Facilitation of smooth induction of anesthesia
3. Post-operative analgesia- by giving a pre-emptive
analgesia
4. Prevention of post-operative nausea and vomiting
 Drug Classes for Premedication
Benzodiazepines
Opioids
Antihistamines
Anticholinergics
Histamine receptor antagonists (H2 antagonists)
Antacids
Proton pump inhibitors
Antiemetics
Gastrokinetic agents
A2-adrenergic agonists
 Routes of Administration
Oral
IV
IM
 Determinants of Drug Choice and Dose in
Premedication
Patients age and weight
Physical status- very young and very old
Level of anxiety
Tolerance of depressant drugs- esp pts with history of illicit
drug use
Allergies
Previous adverse experience with drugs used for pre operative
medications
Inpatient or outpatient surgery-
 Preanesthesia Medication Instructions
Continue on Day of Surgery Discontinue on Day of Surgery
Antidepressant, anti-anxiety, and psychiatric medications
(including MAOI)
Antihypertensives Antihypertensives
Consider discontinuing ACEIs or ARBs 12-24 hr before
surgery if taken only for hypertension; especially with lengthy
procedures, significant blood loss or fluid shifts, use of
general anesthesia, multiple antihypertensive medications,
well-controlled blood pressure; hypotension is particularly
dangerous

Aspirin
with known vascular disease
with drug-eluting stents for <12 months
with bare metal stents for <1 month
Before cataract surgery (if no bulbar block)
Before vascular surgery
Taken for secondary prophylaxis
Aspirin
Discontinue 5-7 days before surgery
- If risk of bleeding > risk of thrombosis
- For surgeries with serious consequences from
bleeding
- Taken only for primary prophylaxis (no known
vascular disease)
Preanesthesia Medication Instructions
Continue on Day of Surgery
Asthma medications
Autoimmune medications
Methotrexate (if no risk of renal failure)
Discontinue on Day of Surgery
Autoimmune medications
Methotrexate (if risk of renal failure)
Entanercept (enbrel), infliximab (Remicade),
adalimumab (Humira): check with prescriber

Birth control pills

Cardiac medications
Clopidogrel Clopidogrel (Plavix)
Patients with drug-eluting stents for <12 Patients not included in group recommended
months for continuation
Patients with bare metal stents for <1 month
Before cataract urgery (if no bulbar block)
Cox-2 inhibitors Cox-2 inhibitors
If surgeon is concerned about bone healing
Preanesthesia Medication Instructions
Continue on Day of Surgery
Diuretics
Triamterene, hydrochlorothiazide
Eye drops
Estrogen compounds
When used for birth control or cancer
therapy
Gastrointestinal reflux medications
Narcotics for pain or addiction
Seizure medications
Statins
Discontinue on Day of
Surgery
Diuretics
Potent loop diuretics
Estrogen compounds
When used to control menopause
symptomsor for osteoporosis
Gastrointestinal reflux medications (Tums)
Herbals and nonvitamin supplements
7-14 days before surgery
Nonsteroidal anti-inflammatory drugs
48 hr before day of surgery
Topical creams and ointments
Preanesthesia Medication Instructions
Discontinue on Day of
Continue on Day of Surgery
Surgery
Hypoglycemic agents, oral
Insulin Insulin
Type 1 diabetes: take ~ 1/3 of intermediate Regular insulin (exception: with insulin
to long-acting (NPH, lente) pump, continue lowest basal rate
Type 2 diabetes: take up to long-acting generally nighttime dose)
(NPH) or combination (7/30) preparations Discontinue if blood sugar level <100
Glargine (Lantus): decrease if dose is >=1
unit/kg
With insulin pump delivery, continue
lowest nighttime basal rate
Steroids (oral or inhaled) Viagra or similar medications
Discontinue 24 hr before surgery
Thyroid medications Vitamins, minerals, iron
Warfarin Warfarin
Cataract surgery, no bulbar block Discontinue 5 days before surgery
Drugs for Pharmacologic Premedication
Before Anesthesia
 Adult Dose
Classification Drug Route
(mg)
Benzodiazepines Midazolam 1-2.5 IV
Diazepam 5-10 Oral, IV
Lorazepam 0.5-2 Oral, IV
Opioids Hydromorphone 0.5-1 IV
Fentanyl 25-100ug IV
Morphine 5-15 IV
Antihistamines Diphenhydramine 12.5-50 Oral, IV
alpha-2 agonists Clonidine 0.1-0.3 Oral, transdermal
Antiemetics Scopolamine 1.5 Topical
Dexamethasone 4 IV
Dolasetron 12.5 IV
Ondanetron 4 IV
Droperidol 1.25 IV
H2 antagonists Cimitedine 200-300 Oral
Ranitidine 150 Oral
Famotidine 20-40 IV, Oral
Antacids Nonparticulate Na citrate 15-30 mL Oral
PPIs Omeprazole 20 Oral
Pantoprazole 40 IV
GI stimulants Metoclopramide 10 Oral, IV
 Potential Complications
With General Anesthesia
Frequently Occurring, Infrequently
Minimal Impact Occurring, Severe
Oral or dental damage Awareness
Sore throat Visual loss
Hoarseness Aspiration
Post-operative Organ failure
nausea/vomiting Malignant
Drowsiness/confusion hyperthermia
Urinary retention Drug reactions
Failure to wake-
up/recover
Death
 Potential Complications
With Regional Anesthesia

Frequently Occurring, Infrequently

Minimal Impact Occurring, Severe
Prolonged Bleeding
numbness/weakness Infection
Post-dural puncture Nerve
headache damage/paralysis
Failure of technique Persistent
numbness/weakness
Seizures
Coma Death
Thank You!