Pre-operative

Evaluation
Dr.Mohd Abdulshafi
Arab board
 General Anesthesia

 Definition:

It is an altered physiologic state in

which, as a result of reversible drug
induced unconsciousness, noxious
stimuli can neither be perceived nor
recalled.
 Anesthesia Management
 Preoperative management.
 Intraoperative management.

 Postoperative management
 Preoperative management
Aim :
Is to ↓ perioperative morbidity and
mortality.
 Establishment of Rapport.

 Preoperative evaluation.

 Informed consent

 Preoperative patient preparation.

 Premedication.
 Pre operative visit.
It is considered negligence if
anesthetic morbidity or mortality
occurs subsequently.
 When it should be done?
 Thepreoperative basic health
assessment may be done anytime
within thirty days of the planned
procedure.
 The purpose of a preoperative
evaluation
 Isnot to "clear" patients for elective
surgery, but rather to evaluate and,
if necessary, implement measures to
prepare higher risk patients for
surgery.

 It
can decrease the length of hospital
stay as well as minimize postponed
or cancelled surgeries.
 Preoperative evaluation
 History.

 Examination.

 Investigation.

 Risk assessment.
 1-HISTORY
 Current medical problems and other
known problems.
 Special habits.

 Medical history.

 History of previous anesthesia and

surgery.
 Family history.

 Review of organ systems.

 Last oral intake.

 2- PHYSICAL EXAMINATION
 Vitalsigns.
 Weight and height.

 Airway.

 Heart and lung.

 Nervous system.

 Other systems appearing affected by

history.
 3- INVESTIGATIONS AND
LABORATORY EVALUATION
 It should be selective and
individualized.

 These tests are :

1.Hematocrite or Hconcentration.
(1 mon)
2.S.glucose or s.creatinine or
BUN.(1 mon)
3.Chest x-rays.(6 months)

4.ECG. (6 months)

5.Liver function tests.(1 month)

6.Coagulation studies.(1 week)

A urine pregnancy test should be
considered for women of childbearing
age.

 Coagulation studies would be

indicated:
1.if the patient is receiving
anticoagulant therapy
2.family or personal history that
suggests a bleeding disorder
3.evidence of liver disease.
 Summary of Recommended Preoperative Laboratory Tests
Depending on the History and Physical Findings
Healthy patient <= 40 years
Healthy patient > 40 years
Cardiovascular disease.
Pulmonary disease.
Abdominal or thoracic surgery
Malnutrition
Hemoglobin, urine screening for pregnancy
in women of childbearing potential
Add ECG and blood glucose (age >=45
years)
ECG, chest radiographs, hemoglobin,
electrolytes, BUN, creatinine, glucose (age
>=45 years or history of diabetes)
Chest radiographs, hemoglobin, glucose
(age >=45 years), ECG (age >40 years);
provide patient with instructions for
incentive spirometry or deep-breathing
exercises
Provide patient with instructions for
incentive spirometry or deep-breathing
exercises
Laboratory tests based on primary disease,
plus albumin and lymphocyte count; if
malnutrition is severe, consider postponing
surgery and providing preoperative
supplementation
 4-RISK ASSESSMENT
Def:
it is detection of pre-,intra-,and postoperative
risk factors which increase mortality and
morbidity.
 ASA physical status classification.
 Other system assessment.

CVS (Goldman's index).

Respiratory assessment.
CNS assessment.
Renal and liver disease assessment.
 ASA physical status classification
class definition Periop. mortality
rate

1 A normal healthy person 0.1%

2 A patient with mild systemic 0.3%
disease.
3 Moderat systemic disease. 3%
4 Severe systemic disease. 15%
5 A moribund patient. 30%
6 A brain dead patient.
E If the procedure is an
emergency.
 Patients who warrant a second examination just
before hospitalization

 Patients with cardiopulmonary

disease.

 childwith an upper respiratory tract

infection to assess the current status
of the infection, to postpone the
procedure because of persistent
fever, wheezing or significant nasal
discharge.
 Surgery-Related Predictors for Risk of
Perioperative Cardiac Complications
High risk Intermediate risk Low risk
Emergency surgery Abdominal or thoracic Breast surgery

Anticipated increased surgery Cataract surgery

blood loss. Head and neck Superficial surgery
Aortic or peripheral surgery Endoscopy
vascular surgery Carotid
endarterectomy
Orthopedic surgery

Prostate surgery
 Patient-Related Predictors for Risk of
Perioperative Cardiac Complications
Major clinical Intermediate clinical Minor clinical
predictors predictors predictors Advanced
Myocardial infarction Mild angina pectoris age Abnormal
<=6 weeks previously Myocardial infarction electrocardiogram
Unstable angina >6 weeks previously Cardiac rhythm other

Decompensated Compensated than sinus

congestive heart failure congestive heart failure Low functional

Significant Diabetes mellitus capacity,

arrhythmias (e.g., history of stroke,
causing hemodynamic uncontrolled
instability) hypertension
Severe valvular
disease (e.g., aortic or
mitral stenosis with
valve area <1.0 cm2)
FIGURE 1.
Schematic figure for determining the need for
preoperative cardiac testing on the basis of
the patient's clinical predictors and functional
status and the risk of the operative
procedure. (METs = metabolic equivalents of
oxygen consumption) Adapted with
permission from the American College of
Cardiology and the American Heart
Association. Guidelines for perioperative
cardiovascular evaluation for noncardiac
surgery.
 Preoperative Basic Health Assessment
 A complete preoperative basic health assessment includes:
Medical History
 Indication for surgical procedure
 Allergies and intolerances to medications, anesthesia, or other
agents (specify reaction type)
 Known medical problems
 Surgical history
 Trauma (major)
 Current medications (prescription, over-the-counter
medications, herbal and dietary supplements, and illicit
drugs)
 Focused review of issues pertinent to the planned anesthesia
and procedure:
 Current status of pertinent known medical problems
 Cardiac status
 Pulmonary status
 Functional status
 Hemostasis status (personal or family history of
abnormal bleeding)
 Possibility of severe (symptomatic) anemia
 Physical Exam
 Weight and height
 Vital signs - blood pressure, pulse (rate and
regularity), respiratory rate
 Cardiac
 Pulmonary
 Other pertinent exam
Electrocardiogram (ECG)
 Recommended for all patients age 55 and over,
within one year prior to procedure. Also, ECGs are
not indicated, regardless of age, for those patients
having cataract surgery.
 Preoperative ECGs are not predictive of cardiac risk.
[Conclusion grade II: See Conclusion Grading
Worksheet A - Annotation #4 (ECGs not Predictive)
in the original guideline document].
Patient Education
 Procedure-specific
 General orientation
 A history and physical examination, focusing
on risk factors for cardiac, pulmonary and
infectious complications, and a determination
of a patient's functional capacity, are
essential to any preoperative evaluation.

 In addition, the type of surgery influences

the overall perioperative risk and the need
for further cardiac evaluation.

 Routine laboratory studies are rarely helpful

except to monitor known disease states.
 Clinical Highlights
 Provide a comprehensive preoperative basic health
assessment for all patients undergoing a diagnostic or
therapeutic procedure as defined in the guideline.
(Annotation #4)
 Most laboratory and diagnostic tests including
electrocardiograms (ECGs) are not necessary with routine
procedures unless a specific indication is present.
(Annotation #6)
 ECGs are not indicated, regardless of age, for those
patients having cataract surgery. (Annotation #4)
 Patients on chronic beta-blocking therapy should continue
taking their beta-blocker medication up to and including the
day of surgery. If beta-blocker therapy is stopped prior to
surgery, patients are at increased risk for complications
postoperatively. (Annotation #6)