Pre- Anesthetic Assessment

Speaker:Hesham Alkharabsheh MD
Assistant Consultant Cardiac Anesthesia
KFSH&RC
PRE-ANESTHESIA ASSESSMENT
Aim and objectives:
​
o Reduce the incidence of cancellation.​
o To include only medically fit patients.​
o Reduce patients and family's anxiety.​
o Early pre-operative assessment..
 Components of the ​
Pre- Anesthetic Evaluation
 Personal Interview:​In PAC (pre-anesthesia clinic) or in the floor ​

 General information ​: MRN,Age,sex ,marital status, Ht,Wt. BMI ,Emergency

contact​

 Review of systems​

 Prior anesthetic experience: (Difficult intubation, delayed emergence,

​
MH, History of Malignant hyperthermia: which is a life threatening complication of
Anesthesia characterized by:​
1- Rapid rise Temperature.​
2- Muscle rigidity.​
3- Tachycardia.​
4- Acidosis ​

 delayed NMB, PONV)​

 Drug allergies​
Physical Examination​
o Airway exam​
o Respiratory,CVS.Neurologicl,Muscloskeletal etc….​

Review of Medical Records​

 Medications​
Substance use (alcohol, tobacco, etc)​
Surgical history​
Surgical Diagnosis (Organ systems involved, Planned
procedure)​
 Airway Examination
Normal :​
Opens mouth normally (Adults: greater than 2 finger
widths or 3 cm) ​
Able to visualize at least part of the uvula and tonsillar
pillars with mouth wide open & tongue out (patient
sitting) ​
Normal chin length (Adults: length of chin is greater
than 2 finger widths or 3 cm) ​
Normal neck flexion and extension without pain /
paresthesias
Airway
Incidence of difficult intubation reported to range
between 0.13 – 5.9%​
It can be predicted and expert anaesthsiologist is
called for the case.​
Evaluation is the first step in management of difficult
intubation. ​
Preparation of tools for difficult Intubation
Airway Examination
Abnormal : ​
Small or recessed chin ​
Inability to open mouth normally ​
Inability to visualize at least part of uvula or tonsils with
mouth open & tongue out ​
High arched palate ​
Tonsillar hypertrophy ​
Neck has limited range of motion ​
Low set ears ​
Signficant obesity of the face/neck​
​
What other feature increase the likelihood of
difficult intubation?
Previous difficult Intubation(D.I)​
Some condition associated with D.I​:
 Short, thick neck (Neck circumference)​
 Diminished neck extension​
 Decreased tissue compliance​
 Large tongue​
 Teeth (Overbite, Large teeth)​
 Decreased TMJ mobility
Mallampati Classification​
Airway Examination
Class I: ​
Soft palate, fauces, uvula, tonsillar pillars
​
Class II: ​
Soft palate, fauces, uvula​

Class III: ​
Soft palate, base of uvula​

Class IV: ​
Hard palate only
ASA Classification
 ​ASA I:
normal healthy patient without organic, biochemical, or psychiatric disease

 ASA II:
mild systemic disease with no significant impact on daily activity e.g. mild diabetes, controlled
hypertension, obesity .

 ASA III:
Severe systemic disease that limits activity e.g. angina, COPD, prior myocardial infarction
 ASA IV:
an incapacitating disease that is a constant threat to life e.g. CHF, unstable angina, renal
failure ,acute MI, respiratory failure requiring mechanical ventilation

 ASA V:
moribund patient not expected to survive 24 hours e.g. ruptured aneurysm

 ASA VI:
brain-dead patient whose organs are being harvested

​
NPO Guidelines
Healthy Adults (No risk factors)​
 No solid foods for a minimum of 6 hours​
 Clear liquids up to 2 hours prior to elective case​
 Oral medications up to 1-2 hours with sip of water​

Pediatric patients​
 Clear liquids up to 2 hours preOp​
 Breast milk up to 4 hours preOp​
 Solid foods, nonhuman milk, formula up to 6 hours preOp
Aspiration​
Who has a higher risk ?
Gastrointestinal Obstruction​
GERD​
Diabetes mellitus​
Recent solid-food intake​
Abdominal distention​
Pregnancy​
Depressed consciousness​
Recent opioid administration​
Upper GI or naso-oropharyngeal bleeding, with or without
trauma​
Emergency surgery
Systems Approach
 Airway​
Examination as previously described​
 Pulmonary​
History – Tobacco use, asthma, SOB/DOE, sleep apnea, wheezing,
cough, etc.​
 Physical exam –
Lung sounds, chest excursion, use of accessory muscles, cyanosis,
clubbing, etc.​
 Cardiovascular​
HTN, CAD, MI, angina, CHF, dysrhythmias, valvular dx, heart sounds,
carotid bruits, peripheral pulses​
 Neurologic​
Mental status, h/o seizures, neuromuscular disease, nerve injury​
 Endocrine​
Diabetes mellitus, thyroid disease, adrenal cortical suppression, etc.
The Patient with​
Pulmonary Disease
Site and Type of Surgery​
 Thoracic and upper abdominal procedures are associated with increased pulmonary
complications​

Type and Severity of Disease​

 Does the disease have a reversible component ?​
 When were they last hospitalized ?​

Interview​
 Exercise tolerance, chronic cough, smoking history​
 What are their current treatment modalities?​

Physical Exam​
 Lungs sounds – wheezing, rhonchi, decreased breath sounds
Pulmonary Disease
Poor lung function: the patient cannot cope with GA.​
The need for ICU, HDU.​
Sleep Apnea – CPAP mask.​
Operation under L.A.? Regional
Cardiac Evaluation

Clinical predictors​
​
Functional capacity​
​
Surgical risk​
​
Non-invasive testing​

Invasive testing
Clinical Predictors of Increased ​
Perioperative Cardiovascular Risk​
(Myocardial Infarction, Congestive Heart Failure, Death)
Minor​
 Advanced age​
 Abnormal EKG(LVH, LBBB, ST-T abnormalities)​
 Rhythm other than sinus (eg, atrial fibrillation)​
 Low functional capacity (eg, unstable to climb one flight of stairs with a
bag of groceries)​
 History of stroke​
 Uncontrolled systemic hypertension​
Intermediate​
 Mild angina pectoris​
 Prior myocardial infarction by history or pathological waves​
 Compensated or prior CHF​
 Diabetes mellitus
Clinical Predictors of Increased ​
Perioperative Cardiovascular Risk​
(Myocardial Infarction, Congestive Heart Failure, Death)
 Major​

 Unstable coronary syndromes​

 Recent myocardial infarction with evidence of important ischemic risk by clinical
symptoms or noninvasive study​
 Unstable or severe angina​
 Decompensated CHF​
​
 Significant arrhythmias​
 High grade atrioventricular block​
 Symptomatic ventricular arrhythmias in the presence of underlying heart disease​
 Supraventricular arrhythmias with uncontrolled ventricular rate​
​
 Severe valvular disease
Functional Capacity​
1MET​
o Can you take care of yourself?​
o ​Can you eat, dress, or use the toilet?​
o Can you walk indoors around the house?​
o ​Can you do light housework, such as dusting or washing dishes?​

4 METs​
o Can you climb a flight of stairs or walk up a hill?​
o ​Can you run a short distance?​
o ​Can you do heavy housework, such as scrubbing floors or lifting or moving heavy furniture?​
o ​Do you participate in moderate recreational activities, such as golf, bowling, dancing, doubles tennis, or
throwing a baseball or football?

​>10 METs​
o Do you participate in strenuous sports, such as swimming, singles tennis, football, basketball, or skiing?​
Surgical Risk
Low surgical risk:​
o Endoscopy​
o Bronchoscopy​
o Cystoscopy​
o Dermatologic procedures​
o Breast biopsy​
o Opthalmologic procedures
Intermediate surgical risk:
​
o Orthopedic surgery​
o Urologic surgery​
o Uncomplicated abdominal surgery​
o Uncomplicated head and neck
High surgical risk:​

o Emergency surgery​
o Cardiac procedures​
o Aortic or vascular surgery​
o Anticipated prolonged surgery​
o Large fluid shifts or blood loss​
o Ex: Whipple, spinal surgery
Other Diseases of Concern
 Diabetic Mellitus​
o Increased risk of CAD, perioperative MI, hypertension, and CHF​
o Consider beta-blockade in diabetics with CAD to help limit myocardial
ischemia​
o Hypo or Hyperglycemia ​

 Renal Disease​
o Altered drug metabolism​
o Fluid management​

 Liver Disease​
o Coagulation abnormalities​
o Altered protein binding and volume of distribution
Obesity
Weight, Height and BMI should be calculated.​

With a BMI of 35 or more there is increased incidence of

complications such as:​
o -Hypoxemia.​
o -Lung collapse.​
o -Chest infection.​
o -DVT.
Risk factors for DVT
 Age >40 years​
 Obesity​
 Varicose veins​
 High oestrogen pill​
 Previous DVT or PE​
 Malignancy ​
 Infection​
 Heart failure / recent infarction​
 Polycythaemia /thrombophilia ​
 Immobility ( bed rest over 4 days)​
 Major trauma​
 Duration of surgery.
National Institute for Clinical Excellence
(NICE)
Recommends:​
1- Identity any health concerns.​
2- Detecting and treating new conditions (Cardiac
arrythmias, Murmurs,..)​
3- Identify any temporary infections (Respiratory, UTI, Skin
infections,..)​
4- Allow patients to talk about concerns and allowing the
doctor to talk about the procedure.
Preoperative Laboratory Testing:
only if indicated from the preoperative history and physical examination.
"Routine or standing" pre operative tests should be discouraged

 CBC : anticipated significant blood loss, suspected hematological disorder (eg.anemia,

thalassemia, SCD), or recent chemotherapy.

 Electrolytes: diuretics, chemotherapy, renal or adrenal disorders

 ECG: age >50 yrs ,history of cardiac disease, hypertension, peripheral vascular disease,
DM, renal, thyroid or metabolic disease.

 Chest X-rays: prior cardiothoracic procedures ,COPD, asthma, a change in respiratory

symptoms in the past six months.

 Urine analysis: DM, renal disease or recent UTI.

 Tests for different systems according to history and examination

Preoperative Preparation
 Anesthetic indications:
o -Anxiolysis, sedation and amnesia. e.g. benzodiazepine(diazepam ,lorazepam)
o -Analgesia e.g narcotics
o -Drying of airway secretions e.g atropine,glycopyrrolate,scopolamine
o -Reduction of anesthetic requirements ,Facilitation of smooth induction
o -Patients at risk for GE reflux :ranitidine ,metoclopramide , sodium citrate

 Surgical indications:
o -Antibiotic prophylaxis for infective endocarditis.
o -Prophylaxis against DVT for high risk patients : low-dose heparin or aspirin
o intermittent calf compression, or warfarin.

 Co-existing Disease indications:

o Some medications should be continued on the day of surgery e,g B blockers, thyroxine.
Others are stopped e.g oral hypoglycemics and antidepressants .
o Steroids within the last six months may require supplemental steroids
Plan of Anesthetic Technique
1. Is the patient's condition optimal?

2. Are there any problems which require consultation or special

tests? “Please assess and advise “

3. 3. Is there an alternative procedure which may be more

appropriate?

4. 4. What are the plans for postoperative management of the

patient?

5. 5. What premedication is appropriate?

Finally, we plan our anesthetic technique :

1. Local or Regional anesthesia with 'standby‘

monitoring with or without sedation.

2. 2. General anesthesia; with or without intubation.

Spontaneous or controlled ventilation is used.

3. 3. Combined regional with general anesthesia.



THANK YOU