Pre-anesthetic evaluation(Pre-operative evaluation)

Thida Uakritdathikarn, M.D.

Department of Anesthesiology

Faculty of Medicine

Prince of Songkla University

(Modified from Dr. Thunchanok Vannasuwankul)

Objectives

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evaluation

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Objectives

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- NPO

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����������� preoperative evaluation

• Doctor-patient relationship

• Surgical illnesses

• Coexisting medical conditions

• Develop a management plan for perioperative anesthetic care

������������� preoperative evaluation

• Reduce peri-operative morbidity and mortality

• Reduce patient anxiety

• Obtain informed consent

Scope of Preoperative Evaluation

• History

• Physical examination

• Laboratory studies

• Anesthetic note

• Guideline for NPO status

• Premedication

Clinical scenario

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Lt. inguinal hernia

Plan : Lt. herniorrhaphy

History

• History in general

• History of coexisting medical illnesses

• History of taking medicine

• History of allergies and drug reactions

• Anesthetic history

• Family History

History in general

• Patient interview

• Review medical record

• Direct discussion with the medical staff and surgical staff

History of coexisting medical illnesses

• GI system

: liver disease

: gastroesophageal reflux symptom

increase risk of pulmonary

aspiration

• Endocrine system

: DM, thyroid, adrenal insufficiency

History of coexisting medical illnesses

• Diabetes

: control blood sugar

: CVS - HT, myocardial ischemia

: CNS - stroke, weakness,

autonomic neuropathy

peripheral neuropathy

: GI - gastroparesis

: KUB

: stiff joint : cervical spine, TM joint

History of coexisting medical illnesses

• Pregnancy

: alter the uteroplacental blood

flow, teratogen, spontaneous

abortion

History of taking medications

- antihypertensive

- antianginal

- antiarrythmic

- anticoagulant

- anticonvulsant

- specific endocrine e.g.insulin, antithyroid drug

History of drug allergies and drug reactions

• Antibiotics

- sulfonamide

- penicillin

- cephalosporin derivatives

• Allergy to shellfish or seafood

- IV contrast dye

- protamine

History of drug allergies and drug reactions

• True allergic reactions

- skin manifestations (pruritus with

flushing)

- face or oral swelling

- shortness of breath

- wheezing

- vascular collapse

Anesthetic history

• Previous anesthetic record

- response to sedative/analgesic

premedication and anesthetic

agents

- Endotracheal tube size

- perianesthetic complications

- postoperative complications

Family history

• Adverse anesthetic outcomes in the family members

• Family history of malignant hyperthermia

Social history

• Smoking

- amount and duration of cigarette smoking

- cessation of smoking (6-8 weeks)

- history of COPD

• Drugs and alcohol

Clinical scenario

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Lt inguinal hernia

Plan : Lt herniorrhaphy

- no underlying disease

- no food and drug allergy

- no smoking and alcohol drinking

Physical examination

• Special attention to the evaluation of the vital signs, airway, heart, lung, abdomen and neurologic examination

• If regional anesthesia is proposed : detailed assessment of the back

Vital signs

• Blood pressure

• Resting pulse

- rate, rhythm, and fullness

• Respiration

- rate, depth, and pattern at rest

• Body temperature

• Pain score (baseline score)

Height and weight

• Calculate BMI : obese

• Estimate drug dosages

• Determine fluid volume requirement

• Calculate acceptable blood loss

• Adequacy of urine output

Airway assessment

General appearance

Tumor of oral cavity

Cystic hygroma

Lymphangioma

Mallampati classification

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Mallampati classification

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Interincisor gap

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: ��(���� 3 .�. (2 fingerbreadths) ���#��#����B��(��(#C(��

Thyromental distance

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• ��(���� 6 .�. (� �3-4 fingerbreadths) ���� #����B��(��(#C(��

�� ����������temporomandibular joint

• �� ��� protrusion of mandible � � grinding

�� ����������temporomandibular joint

Airway

• Mallampati classification

• Interincisors gap

• Thyromental distance

• Forward movement of mandible

• Range of cervical spine motion : flexion and extension

• Document loose or chipped teeth, tracheal deviation

Back

• Deformity

• Infection

Clinical scenario

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Lt inguinal hernia

Plan : Lt herniorrhaphy

- no underlying disease

- no food and drug allergy

- no smoking and alcohol drinking

Clinical scenarioBody weight = 68 kg. , height = 170 cm., BMI = 23.5 kg/m2V/S : BT 37 °°°°C, BP 120/80 mmHg, PR 68/ min. regular,

RR 16/min., pain score 3GA : good consciousness, cooperativeHEENT : not pale, no icteric scleraAirway assessment : normalHeart : normal heart sound, no murmur Lung : breath sound Rt. = Lt., no adventitious soundBack: normalExtremities : no edema

Laboratory studies

• Hematocrit

- Acceptable blood loss: fluid and blood component therapy

- Baseline Hct : blood component preparation

• EKG

- Men > 40 years

- Women > 50 years

Laboratory studies

• Chest X-rays

- age > 15 years (R/O pulmonary TB)

- heavy smokers

- elderly

- major organ system disease

- malignancy

Laboratory studies

• Serum chemistry studies

- BUN/Cr : age > 65 years

- BS

- Electrolytes

- Platelet function

- Coagulation studies

Clinical scenario

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Lt inguinal hernia

Plan : Lt herniorrhaphy

- no underlying disease

- no food and drug allergy

- no smoking and alcohol drinking

PE : unremarkable

Clinical scenario

• Laboratory studiesHb 13 g/dl Hct 40%

Chest x-rays : normal

EKG : normal

Steps of pre-anesthetic evaluation

• History taking

- illness

- coexisting disease

- medication, allergy

- anesthetic history

• Physical examination

• Laboratory investigation

Problem list

• Lt inguinal hernia

American Society of Anesthesiologist (ASA)

Status Disease state

Class 1 healthy patient (no physiologic, physical, or

psychologic abnormalities)

Class 2 mild systemic disease without limitation of dialy

activities

Class 3 severe systemic disease with limits activity but is

not incapacitating

Class 4 incapacitating systemic disease that is constant

threat to life

Class 5 moribund patient not expected to survive 24

hours with or without operation

Class 6 A declared brain-dead patient whose organs are being removed for donor purposes

Emergency case: E

Problem list ASA classification

choice of anesthesiaanesthetic technique

Postpone the operation, consult

Correct problem

Clinical scenario• �������4�� ���& 50 �5 ������6"'�(��,������3�����7�/,��/����6"��.�

��!�$�,�-���� �'�8����%9�������7� Lt inguinal hernia

Plan : Lt herniorrhaphy

- no underlying disease - no food and drug allergy

PE : unremarkableLab : Hb 13 g/dl Hct 40%

film chest : normal

EKG : normal

Problem list: - Lt inguinal hernia

ASA classification 1

Case 2

• �������,�� 68 �5 ������'�(�"����������6"��.��������; 2 �5 ����%9����7�

Rt breast cancer

Plan : Modified radical mastectomy (MRM)- Hypertension 5 �5 on metoprolol 1*1 �4��BP �����; 140-150/ 80-90 mmHg

PE : �.��,��� 60 kg. ��� � 170 cm.

: unremarkable

Lab : Hb 12 g/dl Hct 37 %

film chest : mild cardiomegaly

EKG : sinus rhythm, LVH

BUN 1O mg/dl, Cr O.8 mg/dl

Case 2

• Problem list:

1. Rt breast cancer

2. Well controlled hypertension

3. Cardiomegaly , LVH

4. Geriatric patient (>65 years old)

ASA classification 2

Case 3

• �������4�� 20 �5 ��#'�� RLQ pain ����%9����7� Acute appendicitisPlan : appendectomy

- no underlying disease PE �.��,��� 55 kg. ��� � 170 cm.

V/S : BT 38 °C, BP 120/80 mmHg, PR 80/ min. regular, RR 16/min., pain score 6

Abdomen : tender at RLQ painOthers : WNL

Lab : Hb 13 g/dl Hct 39 %film chest : normalUA : urine sp.gr. 1.023 , no WBC

Case 3

Problem list:

1. Acute appendicitis

2. Fever

ASA classification 2E

ASA and perioperative mortality rate

ASA class Mortality rate (%)

1 0.06-0.08

2 0.27-0.40

3 1.80-4.30

4 7.80-23.00

5 9.40-51.00

Anesthesiologist-patient relationship

• Informing the patients :

- NPO

- Time of surgery

- Preoperative medication

- Aspect of anesthetic management

- Alternatives to the management

plan

Anesthesiologist-patient relationship

• Informing the patients :

- Risks associated with anesthesia

related procedures :

RA, GA, blood transfusion,

vascular cannulations

- Sign informed consent

Anesthesiologist-patient relationship

• Risks associated with RA

- headache

- infection

- local bleeding

- nerve injury

- drug reactions

- GA backup may be necessary

Anesthesiologist-patient relationship

• Risks associated with GA

- sore throat

- hoarseness

- nausea/vomiting

- dental injury

- allergic drug reaction

Anesthetic note

• Relevant positive and negative finding

• A problem lists

• An overall impression : ASA classification

• The anesthetic plan

Guidelines for NPO status

• Adult

: solid food ���� 8 hr

(after midnight of the day before surgery)

• Infant and children

: milk formula, solid food ���� 6 hr

: breast milk ���� 4 hr

• Clear liquid

: up to 2 hr before the procedure

Patient with increase risk of pulmonary aspiration

• Parturient

• Hiatal hernia

• Gastroesophageal reflux symptoms

• Ileus / gut obstruction

• Obesity

• CNS depression

(impaired gag reflex)

Preoperative medication

• Goals

- reduce the patient’s anxiety

- prevent pain during vascular

cannulation, RA, or positioning

- facilitate a smooth induction of

anesthesia

• Sedatives : antianxiety

: provide a restful

night sleep before surgery

• Opioids : relieve pain

• Anticholinergics : drying secretion

• Prophylaxis for pulmonary aspiration

Preoperative medication

Preoperative medication

• Reduce or withhold sedatives and analgesics in

- elderly

- debilitated patients (severely ill patient)

- acutely intoxication

- upper airway obstruction

- trauma

- central apnea

- neurologic deterioration

- severe pulmonary and valvular heart diseases

History takingASA classification

Anesthetic plan

Postpone the operation, consult

Correct problem

Physical examination

Lab. investigation

Pre-anesthetic evaluation

Doctor-patient relationship

Inform patient

Reduce morbiditymortality