1. PREOPERATIVE ASSESSMENT
Hossam M. Ajabnoor
Anesthesia & ICU Asistant Consultant
And Lecturer
School of Medicine, Taibah University

2. INTRODUCTION Importance
Reduce patient risk and morbidity associated with surgery and coexisting diseases
Promote efficiency and reduce costs
Prepare the patient medically and psychologically for surgery and anesthesia

3. ASA basic standards for preanesthetic care
Determining the pt. medical status
Developing an anesthetic care plan
Reviewing with the pt. or a responsible adult this plan

4. Who should perform the preoperative evaluation?
Ideally, the preoperative evaluation is performed by the person who will administer the anesthetic.

5. Goals:
Inform the pt. of the risk → informed consent
Educate the pt. regarding anesthesia Plan
Answer pt. Q.s & reassure the pt. & family
Prohibition of ingesting food
Instruct the pt. about which medications to take or to stop on the day of surgery

6. PREOPERATIVE EVALUATION
It is important for the evaluation to be complete, accurate, and clear, not only to allow the information to be relayed to others who may care for the patient perioperatively, but also for medico legal purposes

7. COMPONANTS HISTORY PHYSICAL EXAMINATION LAB TESTS
CONSULTATIONS (if needed)
PLAN
DISCUSSION WITH PATIENT

8. HISTORY State of health of pt. especially their exercise tolerance
Present illness
Mental status
Medication and substances use(e.g., cigarettes, alcohol)
Previous anesthesia and any complications
Drug allergies and family Hx of MH
review of medical records

9. SPECIFIC AREAS IN Hx CNS Strokes - seizures CVS
Angina - old MI – HTN – rheumatic fever – claudication – arrhythmias
PULMONARY
SOB – cough/sputum – asthma – smoking – recent UTI – pneumonia GI
GERD – alcohol – hepatitis

10. KIDNEYS
Dialysis – ch. Renal impairment
MUSCULOSKELETAL
Arthritis – osteoporosis – weakness
ENDOCRINE
DM – thyroid/adrenal dysfunction
COAGULATION
History of DVT/PE – bleeding tendency
PREGNANCY?
DENTITION

11. PHYSICAL EXAMINATION Vital signs CNS (LOC – evidence of S/M weakness)
Airway
CVS (heart sounds – BP – peripheral edema - peripheral pulses – veins)
Lungs (rales – wheezes – breathing pattern)

12. AIRWAY Cervical spine mobility Short thick neck
Temporomandibular mobility
Large tongue
Prominent central incisors
Diseased or artificial teeth
Thyromental distance and tissue compliance
Ability to visualize the uvula (Mallampati classification)

13. Mallampati classification
Mallampati found a correlation between higher oropharyngeal class and decreased glottic exposure at laryngoscopy. A higher oropharyngeal class combined with a mental space < 2 fingerbreadths may better predict increased difficulty with intubation Performed by having patients in sitting position with their mouth widely open and protruding the tongue completely forward. (A tongue depressor is not used)

14. DIRECT VISUALIZATION, PATIENT SEATED
LARYNGOSCOPIC VIEW
DIRECT VISUALIZATION, PATIENT SEATED
Entire glottic
class I → soft palate, fauces, uvula, and pillars
Posterior commissure
class II → soft palate, fauces, and a portion of the uvula
Tip of epiglottis
class III → soft palate and base of the uvula
No glottal structures
class IV → hard palate only

16. LAB TESTS No evidence supports the use of routine laboratory testing
Use selected laboratory analysis based on the patient's preoperative history, physical examination, and proposed surgical procedure

17. Test Indications Electrocardiogram Chest radiograph
Cardiac and circulatory disease, respiratory disease, advanced age†
Chest radiograph
Chronic lung disease, history of congestive heart disease
Pulmonary function tests, including blood gas analysis and spirometry
Reactive airway disease, chronic lung disease, restrictive lung disease (e.g., scoliosis)
Hemoglobin/hematocrit
Advanced age,† anemia, bleeding disorders, other hematologic disorders
Coagulation studies
Bleeding disorders, liver dysfunction, anticoagulants
Serum chemistries (Na+, K+, Cl-, CO2, glucose)
Endocrine disorders, medications, renal dysfunction
Pregnancy test
Uncertain pregnancy history, history suggestive of current pregnancy

18. CONSULTATIONS
Preoperative consultations fall into two general categories:
Those cases that need more information or expertise to establish or quantify a diagnosis that has implications for anesthetic management. An example is asking a cardiologist to evaluate a 50-year-old man with recent onset of exertional chest pain.
Patients in whom the diagnosis is known, but further evaluation and treatment are needed to optimize their medical condition prior to surgery. Referring patients with poorly controlled diabetes, hypertension, or asthma to an internist are examples.

19. PLAN Type of anesthesia Awake Sedation Local Regional
General anesthesia
Transfer postop
Home
Hospital room (day care / ward)
ICU
Pain control postop

20. Discussion With The Pt. Preop
1. Risks related to anesthesia
Nausea and vomiting
Myalgia
Dental injury
Peripheral neuropathy
Cardiac dysrhythmias
Atelectesis
Aspiration
Stroke
Allergic drug reactions
Death (very unlikely)

21. 2. Preop insomnia and its treatment 3
2. Preop insomnia and its treatment 3. Time, route of administration & effects of preop meds 4. Time of transport to OR 5. Duration of surgery

22. 6. Awakening after surgery in PACU 7
6. Awakening after surgery in PACU 7. Probable presence of catheters on awakening 8. Time to expected discharge from PACU 9. Magnitude of postop discomfort and it treatment

23. ASA PHYSICAL STATUS CLSSIFICATION
Created in 1940
purposes of statistical studies and hospital records
It is useful both for outcome comparisons and as a convenient means of communicating the physical status of a patient
Unfortunately, it is imprecise, and a patient often may be placed in different classes by different anesthesiologists
the higher ASA class only roughly predicts anesthetic risk
Class 1: Healthy patient, no medical problems
Class 2: Mild systemic disease
Class 3: Severe systemic disease, but not incapacitating
Class 4: Severe systemic disease that is a constant threat to life
Class 5: Moribund, not expected to live 24 hours irrespective of operation
An e is added to the status number to designate an emergency operation. An organ donor is usually designated as Class 6.

24. How long should a patient fast before surgery?
Healthy adults with no risk factors for aspiration include no solid food for a minimum of 6 hours, clear liquids up to 2 hours prior to an elective procedure, and oral preoperative medications up to 1-2 hours before anesthesia with sips of water.
Pediatric patients are as follows:
clear liquids up to 2 hours preoperatively
breast milk up to 4 hours preoperatively
solid foods, including nonhuman milk and formula, up to 6 hours preoperatively.

25. How long before surgery must A smoker patient quit smoking?
Carbon monoxide (CO) from cigarette smoking diminishes oxygen delivery to tissues
Nicotine increases heart rate and can cause peripheral vasoconstriction
Within hours of discontinuing cigarettes, CO and nicotine levels return to normal
Bronchociliary function improves within 2-3 days of cessation
sputum volume decreases to normal levels within about 2 weeks
However, there may not be a significant decrease in postoperative respiratory morbidity until after 6-8 weeks of abstinence.

26. List the major goals of premedication
Sedation and anxiolysis
Analgesia and amnesia
Antisialagogue effect
To maintain hemodynamic stability, including decrease in autonomic response
To prevent and/or minimize the impact of aspiration
To decrease postoperative nausea and vomiting
Prophylaxis against allergic reaction

27. What factors should be considered in selecting premedication for a patient?
Patient age and weight
Physical status
Levels of anxiety and pain
Previous history of drug use or abuse
History of postoperative nausea or vomiting or motion sickness
Drug allergies
Elective or emergency surgery
Inpatient or outpatient status

28. List the most commonly used preop medications
Diazepam Oral 5-20 Sedation
Midazolam IV Sedation
Morphine IM 5-15 Analgesia
Meperidine IM Analgesia
Ranitidine Oral, IV 150 mg and 50 mg, respectively Decrease gastric pH
Metoclopramide Oral, IM, IV 5-20 Gastrokinetic
Glycopyrrolate IM, IV Weak sedative, antisialagogue
Scopolamine IM, IV Sedative, antisialagogue
Promethazine IM Antiemetic
Ketamine IM, oral 1-2 mg/kg and 6 mg/kg, respectively Sedation

29. A 3-year-old child presents for an elective tonsillectomy
A 3-year-old child presents for an elective tonsillectomy. His mother reports that for the past 3 days he has had a runny nose. Should you postpone surgery?

30. Viral URI alters the quality and quantity of airway secretions and increases airway reflexes to mechanical, chemical, or irritant stimulation
Some clinical studies have shown associated intraoperative and postoperative bronchospasm, laryngospasm, and hypoxia
There is evidence that the risk of pulmonary complications may remain high for at least 2 weeks, and possibly 6-7 weeks, after a URI
Infants have a greater risk than older children, and intubation probably confers additional risk

31. However, as a practical matter, young children can average 5-8 URIs per year, mostly from fall through spring
If a 4- to 7-week symptom-free interval were rigorously followed, an elective surgery might be postponed indefinitely
Therefore, most anesthesiologists distinguish uncomplicated URI with chronic nasal discharge from nasal discharge associated with more severe URI with or without lower respiratory tract infection (LRI)
Chronic nasal discharge is usually noninfectious in origin and caused by allergy or vasomotor rhinitis
An uncomplicated URI is characterized by sore or scratchy throat, laryngitis, sneezing, rhinorrhea, congestion, malaise, nonproductive cough, and temperature > 38°C

32. More severe URI or LRI may include severe nasopharyngitis, purulent sputum, high fever, deep cough, and associated auscultatory findings of wheezes or rales
It is generally agreed that chronic nasal discharge poses no significant anesthesia risk
In contrast, children with severe URI or LRI almost always have their elective surgery postponed
Probably most anesthesiologists will proceed to surgery with a child with a resolving uncomplicated URI, unless the child has a history of asthma or other significant pulmonary disease

33. THANK YOU