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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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Chronic Obstructive Pulmonary
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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Chronic Obstructive Pulmonary
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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