Preoperative Evaluation Anesthesia

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Preoperative Evaluation

PURPOSE

GOAL

the practitioner's awareness patient's medical

condition

patient's perioperative management plan

information

patient's current and

past medical history

assessment of the patient's

intraoperative risk

patient risk

and the morbidity of surgery


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Preoperative Evaluation

HISTORY

PHYSICAL EXAMINATION

LABORATORY DATA

CURRENT DRUG THERAPY

ASA PHYSICAL STATUS CLASIFICATION

COMPONENT


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American Society of Anesthesiologists

Physical Status Classification


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Johns Hopkins Risk

Classification System (JHRCS) Multifactorial risk assesment

evaluate preoperative medical condition and

nature of surgery as independent factor

nature of surgery is major determinant of risk

Procedure invasiveness

Estimated blood loss


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Components of the Preoperative

Medical HistoryPrescription and over-the-counter

medications, allergies

A history of malignant hyperthermia (MH)

History of sleep apnea

Patient's cardiorespiratory fitness orfunctional capacity

Chest discomfort


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The Preoperative Physical

ExaminationVital signs

Height

Weight

BMI

Inspection of the airway

Evaluation of the heart, lungs, and skin

A basic neurologic examination


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Components of the Airway Examination

Length of the upper incisors

Condition of the teeth

Relationship of maxillary incisors to mandibularincisors

Ability to protrude or advance the lower (mandibular)incisors

Tongue size, visibility of the uvula

Thyromental distance with the head in maximumextension

Length of the neck


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Laboratory Data

Routine laboratory testing for healthy

asymptomatic patients is not recommended

when the history and physical examination fail to

detect any abnormalities. a hematocrit or hemoglobin concentration,

serum electrolyte measurements,

coagulation studies,

an electrocardiogram, and

a chest radiograph


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Preoperative Evaluation of

Patients with Coexisting DiseaseCardiovascular Disease Cardiovascular complications most common

serious perioperative adverse event

Hypertension Ischemic heart disease most common type of

organ damage associated with hypertension.

20mm Hg elevation in systolic BP or 10mm Hg

elevation in diastolic BP above 115/75

doubles thelifetime risk for cardiovascular disease inindividuals 40 to 70 years of age.


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Cardiovascular Disease

Preoperative evaluation

- causes of hypertension,

- other cardiovascular risk factors,

- end-organ damage, and

- therapy

Physical examination

- cardiovascular system,

-pulses,

- vital signs (BP needs to be repeated and previousrecords obtained to establish long-term values),

- the thyroid gland, and

- signs of volume overload


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Hypertension

Patients with long-standing, severe or poorlycontrolled hypertension an ECG anddetermination of blood urea nitrogen (BUN) and

creatinine. Those taking diuretics evaluation of electrolytes

generally recommended elective surgery bedelayed for severe hypertension (diastolic BP>115 mm Hg, systolic BP >200 mm Hg) until BP isless than 180/110 mm Hg


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Revised Cardiac Risk Index

High-risk surgery (intraperitoneal, intrathoracic, orsuprainguinal vascular procedures)

Ischemic heart disease (by any diagnostic criteria)

History of congestive heart failure

History of cerebrovascular disease

Diabetes mellitus requiring insulin[]

Creatinine >2.0 mg/dL


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Pulmonary Disorders

Asthma

Wheezing common symptom in asthmatics but not specific

Spirometry preferred diagnostic test, but a normal resultdoes not exclude asthma.

A methacholine challenge test or a trial of bronchodilatortherapy indicated if spirometry is normal but there is still astrong suspicion of asthma.

Pulmonay Function Test (PFT) have no perioperativepredictive value but in rare instances may be useful to gaugethe severity of disease or the adequacy of therapy.

Typical findings on PFTs are :- reduced Forced Expiratory Volume in 1 second (FEV1)

- normal to increased Functional Vital Capacity (FVC).


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Asthma

Adequate and appropriate medical therapy must be

determined.

The quality of breath sounds, quantity of air movement, and

degree of wheezing are important. Determination of oxygen

saturation by pulse oximetry is useful. Arterial blood gasanalysis is not generally necessary unless the patient is

having a severe acute exacerbation.

Observing the degree of accessory muscle use often gauges

the severity of the bronchoconstriction.

The degree of wheezing does not always correlate with theseverity of bronchoconstriction. severe obstruction, airflow is

dangerously restricted and wheezing diminishes.

Patients taking oral steroids need blood glucose checked and

may require perioperative steroid supplementation.


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Chronic Obstructive Pulmonary

Disease COPD chronic bronchitis and emphysema obstruction toairflow not fully reversible.

It is often due to exposure to pollutants

- cigarette smoke or substances in the environment (airpollution, allergens, grain, dust, and coal)

- 1-antitrypsin deficiency

- chronic infections

- long-standing asthma.

Chronic bronchitis presence of symptoms on most days forat least 3 months for 2 successive years or recurrent

excessive sputum that severely impairs expiratory airflow. Dyspnea, coughing, wheezing, and sputum production

common features.


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Disease The preoperative history and physical examination similar to that for patients with asthma additional emphasis :

- change in amount of sputum,

- color,

- other signs of infection.

A barrel chest and pursed-lip breathing advanced disease.

Typically, FEV1 is reduced because of obstructedairflow, but FVC is increased because of reducedairflow, loss of elasticity, and overexpansion.


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Disease Diffusing capacity is typically decreased degree of hypoxiaand hypercapnia pulmonary hypertension.

Determination of oxygen saturation by pulse oximetry is

appropriate to establish a baseline.

Patients found to be hypoxic or using oxygen may benefit

from arterial blood gas test.

chest radiograph is useful only when infection is suspected.

ECG : right axis deviation, RBBB, or peaked P waves, which

suggest pulmonary hypertension and right ventricularchanges.


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Established risk factors for an increased risk for

pulmonary complications

History of cigarette use (current or >40 pack-years)

ASA-PS scores higher than 2

Age >70 years

COPDNeck, thoracic, upper abdominal, aortic, or neurologic

surgery

Anticipated prolonged procedures (>2 hours)

Planned general anesthesia

Albumin less than 3 g/dL

Exercise capacity of less than two blocks or one flight of stairs

BMI greater than 30


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RENAL DISEASE

Preoperative evaluation of patients with renal insufficiency or failureshould focus on the :

cardiovascular and cerebrovascular systems,fluid volume, and

electrolyte status.

In patients with or at risk for renal disease (especially those with twoof the following: diabetes, poorly controlled hypertension, advancedage), should perform : an ECG and

determination of electrolytes, calcium, glucose, albumin, BUN, andcreatinine

A chest radiograph (infection or volume overload), echocardiogram (for murmurs or heart failure), and

stress testing (see ACC/AHA guidelines) may be indicated in certainpatients.


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HEPATIC DISORDERS

The presence of encephalopathy, coagulopathy, ascites, volumeoverload, and infectivity needs to be determined and exploredpreoperatively.

In selected patients, preoperative evaluation may warrant furthertesting consisting of :

an ECG, CBC with platelet count,

electrolytes,

BUN,

creatinine,

LFTs,

albumin, and PT.

An ammonia level may be helpful in patients with encephalopathy.

A chest radiograph may identify effusions.


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HEPATIC DISORDERS

Patients with severe liver disease increasedperioperative morbidity and mortality.

most common adverse events : bleeding,

infection,

liver failure, and

hepatorenal syndrome

Delaying elective surgery

until after an acute episode of hepatitis or anexacerbation of chronic disease has resolved

until a diagnosis is established if hepatic dysfunctionis newly detected


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Preoperative Fasting Status

a fasting period of 2 hours for clear liquids in allpatients

The volume of liquid ingested is less importantthan the type of liquid ingested.

Neonates and infants 4 hours breast milk

6 hours formula and solids

Noninfants :

6 hours after a light meal8 hours after a meal (includes fried or fatty foods).

ingestion of clear fluids up to 2 to 3 hours beforeanesthesia is acceptable.


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Preoperative Evaluation Anesthesia

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