Preoperative Evaluation of Patients

7/27/2019 Preoperative Evaluation of Patients

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PRE-OPERATIVE VISIT

Preoperative Evaluation of Patients

An anesthetic plan should be formulated that will optimally accommodate the

patient's baseline physiological state, including any medical conditions, previous

operations, the planned procedure, drug sensitivities, previous anesthetic experiences,

and psychological makeup. Inadequate preoperative planning and errors in patient

preparation are the most common causes of anesthetic complications. To help

formulate the anesthetic plan, a general outline for assessing patients preoperatively is

an important starting point. This assessment includes a pertinent history (including a

review of medical records), a physical examination, and any indicated laboratory

tests. Classifying the patient's physical status according to the ASA scale completes

the assessment. Anesthesia and elective operations should not proceed until the

patient is in optimal medical condition. Assessing patients with complications may

require consultation with other specialists to help determine whether the patient is in

optimal medical condition for the procedure and to have the specialist's assistance, if

necessary, in perioperative care. Following the assessment, the anesthesiologist must

discuss with the patient realistic options available for anesthetic management. The

final anesthetic plan is based on that discussion and the patient's wishes.

The Preoperative History

The preoperative history should clearly establish the patient's problems as

well as the planned surgical, therapeutic, or diagnostic procedure. The presence and

severity of known underlying medical problems must also be investigated as well as

any prior or current treatments. Because of the potential for drug interactions with

anesthesia, a complete medication history including use of any herbal therapeutics

should be elicited from every patient. This should include the use of tobacco and

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alcohol as well as illicit drugs such as marijuana, cocaine, and heroin. An attempt

must also be made to distinguish between true drug allergies (often manifested as

dyspnea or skin rashes) and drug intolerances (usually gastrointestinal upset).

Detailed questioning about previous operations and anesthetics may uncover prior

anesthetic complications. A family history of anesthetic problems may suggest a

familial problem such as malignant hyperthermia. A general review of organ systems

is important in identifying undiagnosed medical problems. Questions should

emphasize cardiovascular, pulmonary, endocrine, hepatic, renal, and neurological

function. A positive response to any of these questions should prompt more detailed

inquiries to determine the extent of any organ impairment.

Physical Examination

The history and physical examination complement one another: The

examination helps detect abnormalities not apparent from the history and the history

helps focus the examination on the organ systems that should be examined closely.

Examination of healthy asymptomatic patients should minimally consist of

measurement of vital signs (blood pressure, heart rate, respiratory rate, and

temperature) and examination of the airway, heart, lungs, and musculoskeletal system

using standard techniques of inspection, eg, auscultation, palpation, and percussion.

An abbreviated neurological examination is important when regional anesthesia is

being considered and serves to document any subtle preexisting neurological deficits.

The patient's anatomy should be specifically evaluated when procedures such as a

nerve block, regional anesthesia, or invasive monitoring are planned; evidence of

infection over or close to the site or significant anatomic abnormalities may

contraindicate such procedures.

The importance of examining the airway cannot be overemphasized. The

patient's dentition should be inspected for loose or chipped teeth and the presence of

caps, bridges, or dentures. A poor anesthesia mask fit should be expected in some

edentulous patients and those with significant facial abnormalities. Micrognathia (a

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short distance between the chin and the hyoid bone), prominent upper incisors, a large

tongue, limited range of motion of the temporomandibular joint or cervical spine, or a

short neck suggests that difficulty may be encountered in tracheal intubation.

Laboratory Evaluation

Routine laboratory testing for healthy asymptomatic patients is not

recommended when the history and physical examination fail to detect any

abnormalities. Such routine testing is expensive and rarely alters perioperative

management; moreover, abnormalities often are ignored—or result in unnecessary

delays. Nonetheless, because of the current litigious environment in the United States,

many physicians continue to order a hematocrit or hemoglobin concentration,

urinalysis, serum electrolyte measurements, coagulation studies, an

electrocardiogram, and a chest radiograph for all patients.

To be valuable, performing a preoperative test implies that an increased

perioperative risk exists when the results are abnormal and a reduced risk exists when

the abnormality is corrected. The usefulness of a screening test for disease depends

on its sensitivity and specificity as well as the prevalence of the disease. Sensitive

tests have a low rate of false-negative results, whereas specific tests have a low rate

of false-positive results. The prevalence of a disease varies with the population tested

and often depends on sex, age, genetic background, and lifestyle practices. Testing is

therefore most effective when sensitive and specific tests are used in patients in

whom the abnormality might be expected. Accordingly, laboratory testing should be

based on the presence or absence of underlying diseases and drug therapy as

suggested by the history and physical examination. The nature of the procedure

should also be taken into consideration. Thus, a baseline hematocrit is desirable in

any patient about to undergo a procedure that may result in extensive blood loss and

require transfusion.

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Testing fertile women for an undiagnosed early pregnancy may be justified by

the potentially teratogenic effects of anesthetic agents on the fetus; pregnancy testing

involves detection of chorionic gonadotropin in urine or serum. Routine testing for

AIDS (detection of the HIV antibody) is highly controversial. Routine coagulation

studies and urinalysis are not cost effective in asymptomatic healthy patients.

ASA Physical Status Classification

In 1940, the ASA established a committee to develop a "tool" to collect and

tabulate statistical data that would be used to predict operative risk. The committee

was unable to develop such a predictive tool, but instead focused on classifying the

patient's physical status, which led the ASA to adopt a five-category physical status

classification system for use in assessing a patient preoperatively. A sixth category

was later added to address the brain-dead organ donor. Although this system was not

intended to be used as such, the ASA physical status generally correlates with the

perioperative mortality rate. Because underlying disease is only one of many factors

contributing to perioperative complications, it is not surprising that this correlation is

not perfect. Nonetheless, the ASA physical status classification remains useful in

planning anesthetic management, particularly monitoring techniques.

ASA GRADING

American Society of Anesthesiologists (ASA) grade is the most commonly used

grading system

ASA accurately predicts morbidity and mortality

50% of patients presenting for elective surgery are ASA grade 1

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ASA Grade DEFINITION MORTALITY

I Healthy individual with no systemic disease 0.05

II Mild systemic disease not limiting activity 0.4

IIISevere systemic disease that limits activity but is not

incapacitating4.5

IVIncapacitating systemic disease which is constantly

life-threatening25

VMoribund, not expected to survive 24 hours with or

without surgery50

Informed Consent

The preoperative assessment culminates in giving the patient a reasonable

explanation of the options available for anesthetic management: general, regional,

local, or topical anesthesia; intravenous sedation; or a combination thereof. The term

monitored anesthesia care (previously referred to as local standby) is now commonly

used and refers to monitoring the patient during a procedure performed with

intravenous sedation or local anesthesia administered by the surgeon. Regardless of

the technique chosen, consent must always be obtained for general anesthesia in caseother techniques prove inadequate.

If any procedure is performed without the patient's consent, the physician may

be liable for assault and battery. When the patient is a minor or otherwise not

competent to consent, the consent must be obtained from someone legally authorized

to give it, such as a parent, guardian, or close relative. Although oral consent may be

sufficient, written consent is usually advisable for medicolegal purposes. Moreover,

consent must be informed to ensure that the patient (or guardian) has sufficient

information about the procedures and their risks to make a reasonable and prudent

decision whether to consent. It is generally accepted that not all risks need be detailed

—only risks that are realistic and have resulted in complications in similar patients

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with similar problems. It is generally advisable to inform the patient that some

complications may be life-threatening.

The purpose of the preoperative visit is not only to gather importantinformation and obtain informed consent, but also to help establish a healthy doctor–

patient relationship. Moreover, an empathically conducted interview that answers

important questions and lets the patient know what to expect has been shown to be at

least as effective in relieving anxiety as some premedication drug regimens.

PRE-SCREENING QUESTIONNAIRE

(This form to be posted to patient with appointment for screening)

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Patients Identification Details

Name:

Address:

Postcode:

DoB: Hospital No:

Admitting Consultant: Specialty:

Proposed Operation: Screening clinic date:

Please complete this questionnaire at home and bring it with you when you come to

the

hospital. It will help us to make plans for your care. It will be treated as confidentialmedical information.

A Parent, Guardian or Carer may answer on the patient's behalf.

What would you like us to call you?

(for example, as Mr or Mrs, or by your first name)

Have you ever suffered from any of the following? (if 'yes', please give details)

Heart disease of any sort YES / NO

Chest pain, palpitations or blackouts YES / NO

High blood pressure YES / NO

Rheumatic fever YES / NO

Asthma, bronchitis or other chest disease YES / NO

Breathless on exertion or at night YES / NO

Diabetes or sugar in the urine YES / NO

Kidney or urinary trouble YES / NO

Convulsions or fits YES / NO

Anaemia or other blood disorders YES / NO

Bruising or bleeding problems YES / NO

Blood clots in the legs or lungs YES / NO

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Jaundice (yellowness) YES / NO

Indigestion or heartburn YES / NO

Any other serious illnesses YES / NO

Do you smoke, or have you stopped recently?

(if 'yes' how many a day?) YES / NO

Do you drink alcohol

(if 'yes' how much a week?) YES / NO

Do you have false, capped or crowned teeth? YES / NO

Do you have a pacemaker or any implants? YES / NO

Do you wear contact lenses or a hearing aid? YES / NO

Women; Could you be pregnant? YES / NOAre you on the Pill/HRT? YES / NO

What is your approximate weight?

What is your approximate height?

Are you taking any medicines or drugs? YES / NO

(including inhalers, eyedrops, creams,or herbal

remedies, whether prescribed by your doctor or not)

Are you allergic to any drugs or materials? YES / NO

Please list any previous operations or anaesthetics

………………. Year:

………………. Year:

………………. Year:

Have you, or any member of your family,

had any problems with anaesthetics? YES / NO

Is there anything else which your anaesthetist

or surgeon should know? YES / NO

Do you have particular cultural or religious needs YES / NO

Do you understand that you must not drink alcohol,

drive or operate any machinery for 48 hours after

your anaesthetic? YES / NO

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Do you need the services of an interpreter YES / NO

For Day Surgical Patients only:

Will you have someone to take you home by car? YES / NO

Will you have a responsible adult at home to look

after you overnight? YES / NO

Will you have easy access to a telephone? YES / NO

Signature: Date:

PAEDIATRIC DAY CARE UNITPRE-OPERATIVE ASSESSMENT

Patient label:

DATE OF SURGERY:

DIAGNOSIS:

PROPOSED PROCEDURE:

PAST MEDICAL HISTORY

YES/NO DETAILS

-Has your child been admitted to,or frequently

attends hospital?

-Has your child attended a doctor in the last 4 weeks?

-Has your child had any of the following symptoms

in the last 4 weeks: high temperature,rash, cough,

cold, sore throat?

-Has your child been in contact with an infectious

disease in the last 4 weeks?

-Has your child any heart problems?

-Does your child have a history of asthma or

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chest problems?

-Has your child any kidney problems?

-Has your child ever been jaundiced?

-Does your child bruise easily?

-Has your child ever had any convulsions or seizures?

-Does your child have any other medical conditions?

-Was your child born prematurely (i.e before 37 weeks)?

ASA (American Society of Anesthesiologists) membuat klasifikasi

berdasarkan status fisik pasien pra anestesi yang membagi pasien kedalam 5 kelompok atau kategori sebagai berikut: ASA 1, yaitu pasien dalam keadaan sehat yang

memerlukan operasi. ASA 2, yaitu pasien dengan kelainan sistemik ringan sampaisedang baik karena penyakit bedah maupun penyakit lainnya. Contohnya pasien batu

ureter dengan hipertensi sedang terkontrol, atau pasien apendisitis akut dengan

lekositosis dan

Universitas Sumatera Utarafebris. ASA 3, yaitu pasien dengan gangguan atau penyakit sistemik

berat yang diaktibatkan karena berbagai penyebab. Contohnya pasien

apendisitis perforasi dengan septi semia, atau pasien ileus obstruksi

dengan iskemia miokardium. ASA 4, yaitu pasien dengan kelainan

sistemik berat yang secara langsung mengancam kehiduannya. ASA 5,

yaitu pasien tidak diharapkan hidup setelah 24 jam walaupun dioperasi

atau tidak. Contohnya pasien tua dengan perdarahan basis krani dan

syok hemoragik karena ruptura hepatik. Klasifikasi ASA juga dipakai

pada pembedahan darurat dengan mencantumkan tanda darurat (E =

emergency), misalnya ASA 1 E atau III E.

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Preoperative Evaluation of Patients