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DR.CHARULATHA.R
Preanaesthetic evaluation
 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
goals
 1.patients can safely tolerate anaesthesia for
planned surgical procedure
 2.to mitigate risks associated with overall
perioperative period
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
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
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
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
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
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
Comorbid conditions
 Severity,stability,exarcerbations
 Prior treatments,planned interventions
 Degree of control
 Activity limiting nature of problems
 Medications and schedules
 Recent corticosteroid use
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
Physical examination
 Vital signs
 BMI
 Airway examiation
 Evaluation of heart,lungs ,spine
 Direct observation of exercise tolerance
 Basic neurologic examination
 Carotid bruit
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
Cardiovascular diseaase
 Hypertension
 Ischemic heart disease
 Coronary stents
 Heart failure
 Murmurs and valvular abnormalities
 Rhythm disturbances in preoperative ECG
 Peripheral arterial disease
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
Ischemic heart disease
 Step 1-emergency surgery
 Step2- active cardiac conditions
 Step 3 –low risk surgery
 Step 4- functional capacity
 Step 5- clinical predictors
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
 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
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
 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
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
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
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
Renal function testing
 Diabetes and hypertension
 Cardiac disease
 Fluid overload
 Renal transplantation
 Recent chemotherapy
 Potential dehydration
 Hematuria,oliguria,anuria
Liver function tests
 History of hepatitis
 Jaundice
 Cirrhosis
 Hepatotoxic drug exposure
 Bleeding disorders
 Tumor involvement of liver
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
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
Preoperative risk assessment
 Improves patient’s understanding
 Helps clinical decision making
 Improves perioperative outcomes
 ASA PS classification
 John Hopkins Surgery Risk Classification
System
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
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
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
PFT
 Help differentiate between pulmonary and
cardiac cause of dyspnea
 Assess perioperative risk in lung resection
surgery
 Prognostic value limited
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
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
continue
 Antihypertensive medications
 Cardiac drugs
 Antidepressants,anxiolytics
 Thyroid
 Anticonvulsant
 Asthma
 Steroids
 Statins
 MAO inhibitors
Preoperative fasting status
 Clear fluids -2 hrs
 Breast milk -4 hrs
 Formula milk -6 hrs
 Light meal -6 hrs
 Fried fatty meal -8 hrs
Postoperative pain
management
 Visual analog score
 McGill pain questionnaire
 Uses
 1.patient’s concern
 2.preoperative instructions
 3.improves patient acceptance of regional
anaesthesia
 4.patients with chronic pain syndromes

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preanasthetic evaluation

  • 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
  • 10. Comorbid conditions  Severity,stability,exarcerbations  Prior treatments,planned interventions  Degree of control  Activity limiting nature of problems  Medications and schedules  Recent corticosteroid use
  • 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
  • 14. Cardiovascular diseaase  Hypertension  Ischemic heart disease  Coronary stents  Heart failure  Murmurs and valvular abnormalities  Rhythm disturbances in preoperative ECG  Peripheral arterial disease
  • 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
  • 24. Renal function testing  Diabetes and hypertension  Cardiac disease  Fluid overload  Renal transplantation  Recent chemotherapy  Potential dehydration  Hematuria,oliguria,anuria
  • 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
  • 35. continue  Antihypertensive medications  Cardiac drugs  Antidepressants,anxiolytics  Thyroid  Anticonvulsant  Asthma  Steroids  Statins  MAO inhibitors
  • 36. Preoperative fasting status  Clear fluids -2 hrs  Breast milk -4 hrs  Formula milk -6 hrs  Light meal -6 hrs  Fried fatty meal -8 hrs
  • 37. Postoperative pain management  Visual analog score  McGill pain questionnaire  Uses  1.patient’s concern  2.preoperative instructions  3.improves patient acceptance of regional anaesthesia  4.patients with chronic pain syndromes