This document discusses the importance of preanesthetic evaluation by an anesthesiologist. It aims to ensure patients can safely tolerate anesthesia and mitigate perioperative risks. Key components include documenting medical history, performing examinations, optimizing conditions, ordering tests selectively, and discussing care. History taking and physical exams detect most issues. Tests are only needed based on history, procedure, and anticipated blood loss. The evaluation helps determine a patient's fitness and perioperative risk level. Medication management and fasting guidelines are also reviewed.
2. anaesthesiologist = perioperative physician
Use our unique knowledge and experience to
manage medical complexities related to
surgery
3 % of perioperative adverse events were
related to inadequate preoperative
assessment
3. goals
1.patients can safely tolerate anaesthesia for
planned surgical procedure
2.to mitigate risks associated with overall
perioperative period
4. How do we achieve it?
Document comorbid illness
Perform focussed clinical examination
Optimize preexisting medical conditions
Make selective referrals to specialists
Order preoperative investigations
Initiate interventions to reduce perioperative
risk
Discuss aspects of perioperative care
5. Anaesthesiologist lead PAC
More selective ordering of laboratory tests
Reduced healthcare costs
Reduced patient anxiety
Improved acceptance of regional anaesthesia
Fewer case cancellations on day of surgery
Shorter duration of hospitalization
Lower hospital costs
6. Medical consultation?
Management of unstable medical conditions
before elective surgery
Preop optimization of poorly controlled
medical diseases
Clinically relevant preop diagnostic workup
Uncommon medical disorder
7. Detecting disease
All that is required is clinical examination
History taking -56%
Physical examination -73%
ECGs and chest Xrays -3%
Stress tests -6 %
Respiratory ,urinary,neurolgic-history
8. Components of medical
history
Ask the right question
Indication for surgery and planned procedure
Development of surgical condition and prior
related therapies
Current and past medical problems,pervious
surgical procedures,types of anaesthesia ,any
anaesthesia related complications
allergies
9. Personal history
Tobacco, alcohol ,illicit drug use
Quantitative documentation of tobacco
exposure
Pseudocholinesterase deficiency/ Malignant
hyperthermia
Snoring and excessive daytime sleepiness
Last menstrual period
GE reflux
Excessive bleeding problems
11. METs
Assessment of functional capacity
Metabolic equivalents of the task
Measure of volume consumed during an
activity
Poor exercise capacity may be the cause or
result of cardiopulmonary disease
Inability to perform average levels of exercise
increases risk of perioperative complications
12. Physical examination
Vital signs
BMI
Airway examiation
Evaluation of heart,lungs ,spine
Direct observation of exercise tolerance
Basic neurologic examination
Carotid bruit
13. Components of airway
examination
Length of upper incisors
Visibility of uvula
Compliance of mandibular space
Thyromental distance
Length and circumference of neck
Range of motion of head and neck
Relationship of upper incisors to lower
incisors
15. hypertension
Identify cause,other cardiovascular risk
factors,end organ damage
BP measurement in both arms
Investigations?
Elective surgery delayed when systolic> 200 mm
Hg or diastolic >115 mm Hg
BP less than 180/110 mm Hg
Future appropriate postop management of
inadequately treated hypertension
ACE inhibitors and ARBs
16. Ischemic heart disease
Step 1-emergency surgery
Step2- active cardiac conditions
Step 3 –low risk surgery
Step 4- functional capacity
Step 5- clinical predictors
17. Revised cardiac risk index
High risk surgery
Ischemic heart disease
History of congestive heart failure
History of cerebrovascular disease
Diabetes mellitus requiring insulin
Creatinine >2.0 mg/dL
18. Preoperative anaemia is associated with
increased perioperative cardiac events
Increasing blood transfusion rates does not
decrease perioperative cardiac risk
Anaemia decreases effects of beta blocker
therapy
Increased harm when the patient is bleeding
19. ECG
Patients with symptoms /suggestive of
ischemia
For intermediate to high risk surgical
procedures
Not needed in superficial procedures or simply
because of advanced age
Q waves,RBBB,LBBB - important
20. Statins and beta blockers continued
Beta blockers should be started several days
before the procedure
Caution in patients with cerebrovascular
disease
Aspirin is continued where the risk of cardiac
events exceeds risk of major bleeding
21. Neurologic disease
Cerebrovascular disease- recent stroke orTIA
is a very strong predictor of subsequent
perioperative stroke
Asymtomatic bruit- carotid doppler studies
Seizure disorder- CBC and electrolytes
Parkinson disease
Neuromuscular junction disorders
22. Preoperative tests
Should be based on
1.patient ‘s medical history
2.proposed surgical procedure
3.potential for intraoperative blood loss
Selective testing enhances the standing of
speciality in perioperative medicine
23. CBC
History of increased bleeding
Hematologic disorders
Renal disease
Recent chemo or radiation
Corticosteroid or anticoagulant therapy
Poor nutritional status
Trauma
Anticipated high blood loss
25. Liver function tests
History of hepatitis
Jaundice
Cirrhosis
Hepatotoxic drug exposure
Bleeding disorders
Tumor involvement of liver
26. Coagulation testing
Known bleeding disorders
Previous excessive intraoperative bleeding
Hepatic disease
Poor nutritional status
Anticoagulants
Routine testing not needed unless
coagulapathy is suspected or known
27. Chest radiograph
No evidence indicates that routine
preoperative chest radiographs provide
prognostically important information for
assessing patients perioperative risk
Rales or rhonchi
Advanced copd/suspected pulmonary edema
Pulmonary/mediastinal masses
Aortic aneursym
28. Preoperative risk assessment
Improves patient’s understanding
Helps clinical decision making
Improves perioperative outcomes
ASA PS classification
John Hopkins Surgery Risk Classification
System
29. ASA PS
1- a normal healthy patient
2- a patient with mild systemic disease
3- a patient with severe systemic disease
4- a patient with severe systemic disease that
is a constant threat to life
5- a moribund patient who is not expected to
survive without operation
6-declared brain dead donor
30. Role of specialized testing
Resting echocardiography-
Valves
Pulmonary hypertension
Fixed wall motion abnormalities
Ventricular function
Dyspnea of unknown origin
Recent altered clinical status in a known heart
failure patient
31. CPET
Non invasive global assessment of exercise
capacity
Involves a patient exercising on a treadmill or
bicycle for 8 to 12 minutes
Continuous measurement of respiratory gas
exchange
Poor exercise capacity associated with
increased postoperative mortality/morbidity
32. PFT
Help differentiate between pulmonary and
cardiac cause of dyspnea
Assess perioperative risk in lung resection
surgery
Prognostic value limited
33. Medication management -stop
Clopidogrel-7 days before surgery
Ticlopidine -14 days
Insulin- short acting –discontinue
Type 1 diabetes- 1/3 rd of long acting morning
dose
Type 2- upto ½ of long acting or combination
OHAs
Diuretics –except thiazides
34. stop
Warfarin- 4 days before surgery except for
patients having cataract surgery withot
bulbar block
NSAIDS – 48 hrs before surgery
Sildenafil-24 hrs before surgery
ACEI and ARBs