PRE ANAESTHETIC EVALUATION

DEFINITION
The process of clinical assessment that precedes the delivery of anaesthesia care for surgery and for non surgical procedure

ASA task force on pre anaesthetic evaluation, 2002.

OBJECTIVES

Evaluate the patients medical condition. Optimize the patients medical condition for anaesthesia and surgery. Determine and minimize the risk factors associated with anaesthesia. anaesthesia. Plan anaesthesia technique and perioperative care for the patient. Develop rapport with the patient.

OBJECTIVES

Inform and educate the patient regarding the nature of surgery, type of anaesthesia and periperioperative care. Obtain consent.

GENERAL PRINCIPLES
1. Pre anaesthetic assesment should be performed

by the anaesthesiologist who is to conduct anaesthesia. anaesthesia. 2. May be conducted as an personal interview in the ward ,operating theatre or pre-anaesthetic clinic preusing preset questionnaire. 3. Should be performed at an appropriate time before scheduled surgery.

ASA task force on pre anaesthetic evaluation, 2002

GENERAL PRINCIPLES
4.

Inputs from other medical specialties maybe required.

5. In case of emergency surgery where early consultation is not possible the anaesthesiologist is still responsible for the pre anaesthetic assessment.

ASA task force on pre anaesthetic evaluation, 2002

BENEFITS OF PREOPERATIVE EVALUATION

Detection and modification of risk factors. Planning of post-op pain management. post To keep patient informed about his anaesthesia plans. To reduce anaesthesia related complications. Minimize costs of the patient.

HISTORY AND PHYSICAL EXAMINATION ARE THE MOST IMPORTANT ASSESSORS FOR DISEASE AND RISK

PREOPERATIVE ASSESMENT STEPS

Patient particulars: 1.Name 2.Age 3.Sex 4.Address 5.Occupation 6.Date of admission 7.IP number

COMPONENTS OF HISTORY TAKING

History of presenting illness Past history Treatment history Personal history Family history Menstrual history Obstetric history

HISTORY OF PRESENTING ILLNESS

Onset Duration Progression Therapies related to the current problem

RESPIRATORY SYSTEM SYMPTOMS

Cough Expectoration Dyspnea Fever with chills Sore throat Nasal congestion Wheeze Asthma / TB / COPD / Sleep apnea

CARDIOVASCULAR SYMPTOMS

Chest pain Shortness of breath Fatigue Orthopnea PND Nocturnal cough Peripheral edema Past h/o syncope

PAST HISTORY

H/O Diabetes, Hypertension, IHD, TB, Asthma, Epilepsy, Cerebrovascular accidents. H/O any past surgeries , hospital admissions. H/O Anaesthesia exposure. H/O Contact eg: TB , STDs.

TREATMENT HISTORY

Dose of medication Duration of treatment Regularity Side effects H/O any Ayurvedic / homeopathic treatment

MENSTRUAL HISTORY
Onset of menarche Last menstrual date Duration of normal menstrual flow Amount of blood loss Any irregularities Menopause

OBSTETRIC HISTORY

LMP Number of children H/O last child birth H/O any abortions in the past H/O indications for the present caesarean section or in the past if any

PAEDIATRIC CASES

Birth history Development history Immunization history H/O failure to thrive H/O congenital diseases H/O drug intake

H/O Allergic Reactions:

Antibiotics Induction agents

Propofol

Reported allergy to anesthesia

Malignant Hyperthermia Halogenated agents succinylcholine Atypical Pseudocholinesterase

H/O difficulty with prior anaesthetic procedure:

Has anyone in your family experienced unusual or serious reactions to anesthesia?

Malignant hyperthermia

Previous history of difficulty under anesthesia

Difficult Intubation Significant PONV Review available old records

Social History/Personal History

Smoking Alcohol Recreational drug use

Smoking:

Productive Cough, H/O haemoptysis. haemoptysis. How many pack years? Eliminate cigarette use for 2-4 weeks prior to 2elective surgery to reduce complications. If not possible at least 12-24 hrs prior to surgery. 12Assess need for further pulmonary evaluation

Alcohol:

SelfSelf-reporting of use typically underestimates actual use Acute intoxication

Lowers anesthetic requirements Predisposes to hypothermia and hypoglycemia

Withdrawal
Increase anesthetic requirements Hypertension Tremors Delirium Seizures

Recreational drugs:
Define types, routes, frequency, last used

Stimulant abuse
Palpitations True angina Lowered threshold for serious arrhythmia Convulsions

Routine use of narcotics/benzodiazepines (whether prescribed or illegal) may significantly increase the dose required to induce anesthesia or maintain anesthesia.

Routine use of recreational drugs will impact postpost-op pain requirements.

EXERCISE TOLERANCE
1 MET Can you take care of yourself?
Eat or use the toilet? Walk a block or two on level ground at 2-3 mph 2Do light work around the house like dusting or washing dishes?

4 MET Climb a flight of stairs or walk up a hill?

Walk on a level ground at 4mph? Run a short distance? Do heavy work around the house like scrubbing floors or lifting heavy furnitures?

EXERCISE TOLERANCE
10 MET Participate in strenuous activities and sports
like swimming, tennis, football, basketball.

Poor Exercise Tolerance (could not walk four blocks/climb two flight of stairs)independently predicted a complication with an odds ratio of 1.94.

GENERAL PHYSICAL EXAMINATION

Level of consciousness Build and nourishment and assessment of BMI Height and weight of the patient. Pallor, icterus, cyanosis, clubbing, palpable icterus, lymph node. Baseline Vital Signs:

Blood pressure Resting pulse Respiration JVP

Venous access sites.

Physical Exam:

Specific to Regional Anesthesia Detailed assessment of extremity Detailed assessment of back Deformities Infection History of injury Previous back surgery Chronic pain issues

AIRWAY ASSESSMENT

NARES MOUTH OPENING / CAVITY TEETH- PROTRUDING, LOOSE, DENTURES PALATE PROGNATHISM T-M JOINT MOVEMENTS NECK MOVEMENTS VOICE- STRIDOR, RECENT CHANGE, HOARSENESS

ASSESSMENT IN REGARD TO MASK VENTILATION

BONES

B - Beard O - Obesity BMI > 26 WT > 110 Kg N - No teeth E -Elderly (age>55 yrs) S - Snoring history

Neck Movement Range Assessment Direct assessment

Neck flexion on chest by 25 - 30 & extension of atlanto occipital joint by 85 makes laryngoscopy easy Patient should be able to touch manubrium sternum with his chin Flexion Patient should be able to see the ceiling without raising his eyeball - Extension

MEASUREMENT OF ATLANTO-OCCIPITAL ATLANTOANGLE

(BELLHOUSE AND DORE)
GRADE I - >35 >35 GRADE II - 22 - 34 22 34 GRADE III - 12- 21 12 21 GRADE IV- < 12 IV- 12 (NORMAL ANGLE OF EXTENSION IS 35 35 OR MORE)

Neck movement range assessment In direct assessment

Prayer sign

Palm print sign

MALLAMPATI CLASSIFICATION
(SAMSOON AND YOUNG MODIFICATION)

MALAMPATI CLASS

Class 1 Faucial pillars, soft palate, uvula could be visualized Class 2 Uvula, fauces and soft palate could be visualized but tonsillar pillars was masked by base of the tongue Class 3 - Only soft palate and hard palate could be visualized
Mallampati S Rao etal., A clinical sign to predict difficult tracheal intubation: a prospective study CAN ANAESTH SOC J 1985 / 32:4/ pp429 - 34

MALAMPATI CLASSIFICATION
Modified by Samsoon & Young Class 4 Only hard palate seen Test has to be repeated twice to avoid errors

Grade I & II are associated with easy intubation while grade III & IV are associated with difficlut intubation.

FAILURE OF MALAMPATTI CLASSIFICATION

Failure to include evaluation of two important factors affecting visualization of glottis Neck mobility 2. Size of mandibular space 3. Does not tell us about the space anterior to larynx
1.

TESTS FOR MANDIBULAR DISTANCE

THYROMENTAL DISTANCE (PATIL TEST) STERNOMENTAL DISTANCE ( SAVVA TEST) MANDIBULOHYOID DISTANCE

THYROMENTAL DISTANCE
y y y

Distance of mentum to thyroid notch. Patients neck fully extended. Helps to determine how readily laryngeal axis will fall in line with pharyngeal axis with patient's neck fully extended Difficult < 3 Fingers 0R < 6 CM Less difficult 6-6.5 CM 6Normal > 6.5 CM

STERNOMENTAL DISTANCE

Distance from upper border of manubrium to tip of mandible with neck fully extended and mouth closed

<12.5cm is significant

MANDIBULO HYOID DISTANCE

Distance between mentum and hyoid bone. Grade I : > 6cm Grade II: 4 6cm Grade III : < 4cm Impossible laryngoscopy & Intubation

INTER INCISSOR GAP

4.6 cm or more normal-easy insertion of normallaryngoscope blade. <3 cm difficulty in intubation. <2.5 cm- LMA insertion difficult. cm-

Predictive Performance of Three Multivariate Difficult Tracheal Intubation Models: A Double-Blind,Case-Controlled Study Mohamed Naguib, MB, BCh, MSc, FFARCSI, MD*, Franklin L. Scamman, MD, Cormac OSullivan, CRNA, John Aker, CRNA, Alan F. Ross, MD, Steven Kosmach, MSN, RN*, and Joe E. Ensor, PhD

WILSON SCORING SYSTEM

0 WEIGHT HEAD & NECK MOVEMENT JAW MOVT INTERDENTAL MANDIBULAR RECESSION PROTRUDING INCISORS < 90 Kg >90 > 5 Cm MILD MILD 1 9090-110 Kg 90+ 90+10 5 MODERATE MODERATE 2 > 110 Kg < 90 < 5 Cm SEVERE SEVERE

RISK SCORE BETWEEN 0-10. 0 Score <5 is associated with easy laryngoscopy, 6-7 laryngoscopy, 6moderate difficulty and >8 have severe difficulty.
Predictive Performance of Three Multivariate Difficult Tracheal Intubation Models: A Double-Blind, Case-Controlled Study, Anaesth Analg 2006;102:818-24

Dr. Binnions LEMON Law: An easy way to remember multiple tests

Look externally. Evaluate the 3-3-2 rule. Mallampati. Obstruction Neck mobility.

Physical Exam:
RESPIRATORY SYSTEM

(contd) contd)

Deviation of trachea Lungs

Wheezes Crepitations Correlate what you hear with observation of how

patient is breathing. easy v/s labored Use of accessory muscles Breathing pattern. Chest deformities.

Physical Exam: (contd) contd)

CARDIOVASCULAR SYSTEM

Heart Murmur Pericardial rub

Physical Exam:

(contd) contd)

Abdomen Distention Ascites Predisposition to regurgitation Compromise ventilation

Physical Exam:

(contd) contd)

Extremities Clubbing Cyanosis Cutaneous infection No IV cannulation No regional nerve block

Physical Exam:

(contd) contd)

CNS Document neurological status Cranial nerve function Cognition Peripheral sensorimotor function

ASA Physical Status Classification

ASA I a normal healthy patient ASA II a patient with mild systemic disease (mild diabetes, controlled HTN, obesity). ASA III a patient with severe systemic disease that limits activity (COPD, angina, prior MI). ASA IV a patient with an incapacitating disease that is a constant threat to life (CHF, renal failure). ASA V a moribund patient not expected to survive 24 hours (ruptured AAA). ASA VI brain dead patient whose organs are being harvested. E for emergent operations add the letter E after the classification.

NYHA CLASS CLASS I

SYMPTOMS No limitation of physical activity, ordinary activity does not cause fatigue ,palpitation or syncope.

CLASS II

Slight limitation of physical activity, ordinary activity results in fatigue, palpitation and syncope.

CLASS III

Marked limitation of physical activity, less than ordinary activity results in fatigue, palpitation and syncope. Comfortable at rest.

CLASS IV

Inability to perform any physical activity.

RISK FACTORS FOR PULMONARY COMPLICATIONS

        

History of cigarette use (current or >40 pack-year) packASAASA-PS score >2 Age > 70 yrs COPD Neck, thoracic, upper abdominal, aortic or neurologic surgeries Anticipated prolong procedure>2 hrs Albumin <3gm/dL <3gm/dL BMI>30 Exercise capacity <2 blocks

Preoperative labs:

Hematocrit and Hemoglobin Pre-surgical Standard of Care Pre Hcts of 25-30% tolerated in healthy pt. 25 Low Hemoglobin may result in ischemia in patient with history of CAD Evaluate each patient individually for the etiology and duration of their anemia

Will the surgery involve significant blood loss? NO Is the patient <6 mnths or >40 years or a female. YES NO
Does the patient have any of the following? Anaemia, leukemia,cancer or abnormal bleeding or renal disease? Does the patient smoke >half pack of ciggarettes a day? Does the patient takes anticoagulants?

Obtain Hb or haematocrit if neither was obtained in past 2 month or if patient has donated blood in past 2 months

NO Surgery may be proceeded without haemoglobin or haematocrit.

RBS/FBS/PPBS
H/O Diabetes H/O Nocturia H/O use of steroids (eg : in asthmatics (eg or COPD patients) > 35yrs age Obese (BMI> 33)

Does the patient has CVS symptoms? Symptoms suggestive of renal pathology? H/O UTI History or present complain of haematuria Diabetes Mellitus Liver disease Morbid obesity Age >65 yers old

NO

Does the patient take steroid,diuretics ? OR YES Has there been recent change in patient diet to high protein containing diet?

YES NO Obtain routine urine analysis,serum urea and creatinine. Surgery can be proceeded without urea,creatinine or routine urine examination.

SERUM ELECTROLYTES
Diabetes Dialysis Diuretics Dehydration High risk surgeries

LIVER FUNCTION TEST

Alcoholics H/O jaundice H/O gall stones H/O bleeding tendencies H/O intake of oral anti-coagulants anti H/O malignancy

ECG
INDICATED IN : All patients >50yrs (M) > 55yrs ( F ) H/o CVS disorders or symptoms & signs Diabetes . Smokers . H/o vascular surgeries. H/O GERD.

CHEST X-RAY
Does the patient has one of the following condition? 1. Cardiovascular disease? 2. Pulmonary symptoms or known pulmonary disease( eg: TB,Asthma,COPD) 3. Diagnosed to suffer from Malignancy or has been treated for the same

NO

YES

Obtain Chest X-ray if none has been obtained since past 2 months or there has been recent change in symptoms.

1.Does the patient has signs and symptoms of on going chest infections( eg: cough, productive sputum,recent change in sputum colour) 2.Change in Cardiovascular symptoms 3.Travel or exposure to high risk areas of tuberculosis or other chest disease or history of contanct with individuals suffering from the same. 4.H/O trauma to the chest or in case of RTA.

YES

5.History or symptoms of rhematoid arthritis,thyroid goitre or physical evedence of deviation of traches

COAGULATION TESTING
Includes bleeding time, clotting time, APTT,INR and P-Time. Family H/O coagulopathies. H/O anticoagulant use. H/O hepatic disorder.

PULMONARY FUNCTION TESTS

Indications - COPD - Shortness of breath - Orthopnea - Smokers - Lung surgeries

OTHER LAB INVESTIGATIONS

Serological tests - HIV - HBsAg - VDRL Total count , Differential count , ESR Platelet count. Arterial blood gas analysis.

Informed Consent:

The anesthetic plan, alternatives, and potential complications must be discussed in terms and in a language that is understandable to the patient. Aspects of care pre-operatively and postprepostoperatively:

Intubation Post op ventilation/ICU Invasive monitoring Regional anesthesia techniques Potential for blood product use

Informed Consent: Consent:

Alternative plan
Necessary if planned procedure fails or

there is a change in clinical circumstance.

Associated Risks
Discuss in a manner that a reasonable

person would find helpful in making a decision. Complications that occur with high frequency.

Informed Consent Extenuating Circumstances

Anesthesia procedures may proceed without consent in emergency situations.

NPO status: Pre-op Fasting Guidelines Pre Prescribed period of time before a procedure when a patient is not allowed the oral intake of liquids and solids

Practice Guidelines, Anesthesiology 2011;114:495-511 2011;114:495-

NPO status: Preop Fasting Guidelines

Recommendations for all age groups Ingested Material Fasting Period(hrs) Clear liquids 2 hrs Breast milk 4 hrs Infant formula 6 hrs NonNon-human milk 6 hrs Light solid foods 6 hrs

Practice Guidelines, Anesthesiology 2011;114:495-511 2011;114:495-

NPO guidelines:

Clear liquids include; water, sugar water, apple juice, nonnon-carbonated soda, pulp-free juices, clear tea, pulpblack coffee. Medications can be taken PO with up to 150ml of water in the hour preceding anesthesia induction. Recommendations apply to healthy patients, elective surgery. Following the recommendations does not guarantee that gastric emptying has occurred.
Practice Guidelines, Anesthesiology 2011;114:495-511 2011;114:495-

A little pre-planning goes a long preway THANK YOU

REFERENCES

Millers Anaesthesia 7th edition Harrisons Principles of Internal Medicine 17th edition. Clinical Anesthesia- Barash Practice Advisory for Preanesthesia Evaluation A Report by the American Society of Anesthesiologists Task Force on preanesthesia evaluation Anesthesiology 2002 96:485-96 Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures An Updated Report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters : Anesthesiology Vol 114- No 3 Mar 2011

Predictive Performance of Three Multivariate Difficult Tracheal Intubation Models: A Double-Blind,Case-Controlled Study Mohamed Naguib, MB, BCh, MSc, FFARCSI, MD*, Franklin L. Scamman, MD, Cormac OSullivan, CRNA, John Aker, CRNA, Alan F. Ross, MD,Steven Kosmach, MSN, RN*, and Joe E. Ensor, PhD