PREOPERATIVE

EVALUATION

Liezl C. Rivero,M.D.
2nd Year Resident
 PREOPERATIVE EVALUATION

 There is no standard anesthetic

 An anesthetic plan should be formulated
that will optimally accommodate the
patients baseline physiologic state
including any medical and surgical
illness, planned procedure, drug
sensitivities, previous anesthetic
experiences and psychological make up.
 ANESTHETIC PLAN
 Premedications- P.O.,IV,IM
 Type of anesthesia
1.General anesthesia- airway
management,induction, maintenance,
muscle relaxation
2.Local/Regional anesthesia- technique,
agents,monitored anesthesia care,
supplemental O2, sedation
 ANESTHETIC PLAN

3.Intraoperative Management- monitoring,

positioning, fluid management, special
techniques
4.Postoperative Management- pain control,
intensive care(postoperative
ventilation,hemodynamic monitoring)
 ASSESSMENT
 Preoperative History
1.Current problem
2.Other known medical problems/current
treatments
3.Complete medication history- allergies,
drug intolerances(GI upsets),present
therapy(prescription, non-prescription)
 PREOPERATIVE HISTORY
non- therapeutic(alcohol, tobacco), illicit
drugs such as cocaine,marijuana, heroin,
etc.
4.Previous anesthetics, surgeries and
obstetric deliveries.
5.Family history
6.Review of organ systems – general
survey including activity level, respiartory
 cardiovascular,renal,GI,hematologic,neuro
logic, endocrine,psychiatric, ortho, derma
7.Last oral and fluid intake
 PHYSICAL EXAMINATION
 Helps detect abnormalities not apparent
from the history, while the history helps
focus the examination on the organ
systems that should be examined closely:
1.Vital signs(BP, heart rate, RR, temp.)
2.Airway
3.Heart
4.Lungs
 PHYSICAL EXAMINATION
5.Extremities
6.Neurologic exams-neurologic deficits
7.Patients dentition- loose or chipped teeth,
presence of caps,bridges, dentures, etc.,
significant facial abnormalities,
micrognathia(short distance bet. chin and
hyoid bone),prominent upper incisors,
large tongue, limited range of motion of
TMJ or cervical spine, short neck
 LABORATORY EVALUATION
 Hgb and Hct determination
 Urinalysis, Serum glucose,BUN, CREA
 Serum electrolytes
 Coagulation studies(CTBT,PTT)
 ECG AND CXR
 Pregnancy testing
 ASA PHYSICAL STATUS
CLASSIFICATION
 1961- 5 category for use in assessing a
patient preoperatively.A 6th category was
later added to address the brain dead
organ donor.
CLASS DEFINITION
I A normal healthy patient
II Patient with mild systemic
dse.& no functional limita
tions
 ASA PHYSICAL STATUS
CLASSIFICATION
CLASS DEFINITION
III Moderate to severe systemic
that results in some functional
limitation.
IV Severe systemic dse.that is a
constant threat to life & functio
nally incapacitating
 ASA PHYSICAL STATUS
CLASSIFICATION
CLASS DEFINITION
V Moribound patient who is not
expected to survive 24 hours
with or without surgery.
VI A brain dead patient whose
organs are being harvested.
E If the procedure is an emergency
 INFORMED CONSENT
 The operative assessment in giving the
patient a reasonable explanation of the
options available for anesthetic
management.
 To ensure that the patient or guardian has
sufficient information about the procedure,
risks, complications that maybe life threa-
tening inorder to make a reasonable and
prudent decision whether to consent.
 DOCUMENTATION

PREOPERATIVE NOTES

INTRAOPERATIVE ANESTHESIA
RECORD

POSTOPERATIVE NOTES
 PREOPERATIVE NOTES
 Should be written in the patients chart
 Describe all aspects of the preoperative
assessment including the medical history,
physical exam.,laboratory results, ASA
classification & recommendations of any
consultants.
 PREOPERATIVE NOTES
 Describes the anesthetic plan & includes
the informed consent.
 documentation of the informed consent
usually takes the form of a narrative in the
chart indicating that the plan, alternative
plans, their advantages & disadvantages
(including risks & complications) were pre
sented, understood & agreed by the patient.
INTRAOPERATIVE ANESTHESIA
RECORD
 Useful intraoperative monitor
 Reference for future anesthetics for that
patient
 Tool for quality assurance
 Should be pertinent and accurate as
possible
 Should document all aspects of anesthetic
care in the OR including the ff:
INTRAOPERATIVE ANESTHESIA
RECORD
 Preoperative check of anesthesia machine
and other equipment.
 Time of administration,dosage & route of
intraoperative drugs.
 All intraoperative monitoring including lab.
Measurements, blood loss and urinary
output.
 IV fluid administration and transfusion
INTRAOPERATIVE ANESTHESIA
RECORD
 All procedures such as intubation,NGT,
invasive monitors
 Induction, positioning, surgical incision and
extubation
 Unusual events or complications
 Vital signs are recorder graphically at least
every 5 minutes & other monitoring data
are usually entered graphically.
INTRAOPERATIVE ANESTHESIA
RECORD
 The condition of the patient at the end of
the procedure.
 Descriptions of the techniques or
complications are handwritten.
 Name of surgeons and his assistants
 Printed name and signature of the
anesthesiologist
 Name of scrub nurses
INTRAOPERATIVE ANESTHESIA
RECORD
 Postoperative procedure and
postoperative diagnosis
 POSTOPERATIVE NOTES
 The anesthesiologists immediate respon-
sibility to the patient does not end until the patient has
completely recovered from the effects of anesthesia.

 Accompany the patient to the PACU, ensure normal

vital sign & patient condition is stable.

 Prior to discharge from PACU, a discharge note

should be written to document the patients recovery
from anesthesia, any apparent post anesthesia related
complicatrions,immediate post op condition of the
patient and patients disposition(discharge to an
OPD,inpatient ward,ICU).
 POSTOPERATIVE NOTES
 Inpatients should be seen again at least
once within 48 hours after discharge from
PACU.
GOOD DAY!
THANK YOU !