Preoperative
Assessment
of the Surgical Patient
OUTLINE
• Introduction
• Patient assessment
• History
• Examination
• Investigation
• Specific preoperative problems
• Preoperative assessment in
emergency
• Assessment at high-risk patient
• Airway assessment
• Documentation and consent
INTRODUCTION
The pre-operative assessment is an opportunity to identify
co-morbidities that may lead to patient complications during
the anesthetic, surgical, or post-operative period.
Patients scheduled for elective procedures will generally
attend a pre-operative assessment 2-4 weeks before the
date of their surgery.
Goals
To explain to the patient the nature of the illness implications of surgery and
prognosis.
Identification of potential operative mortality and postoperative morbidity.
To assess the fitness for operation.
Identification of the risks of potential postoperative complications and prophylactic
measures.
Careful preoperative planning minimize the unwanted effects of
physiological changes stress of major surgery can cause.
Increased oxygen demand by about 40%.
Cytokine release-related inflammatory changes
Endocrine responses
Hypercoagulability and
Redistribution of fluid between compartments……. may last several postoperative
day.
To assess functional reserve but also the formulation of advice on
optimization, to best cope with the anticipated operative stress.
History
History of the Presenting Complaint
A brief history of why the patient first attended
What procedure they have subsequently been scheduled for.
Past Medical History
A full past medical history (PMH) is required, with the following
specifically asked about:
Cardiovascular
● Ischemic heart Respiratory
disease – angina, myocardial ● Chronic obstructive
infarction pulmonary disease
● Hypertension ● Asthma
● Heart failure ● Respiratory infections
● Dysrhythmia Screening questions
● Peripheral vascular Dyspnea
disease Chronic cough
● Deep vein thrombosis Wheeze
Obstructive sleep apnea
Screening questions Chest pain
Exertional dyspnea
Paroxysmal nocturnal Gastrointestinal
● Peptic ulcer disease
dyspnea
Exertional chest pain Gastro-
Syncopal episodes oesophageal reflux
Palpitation ● Liver disease
Orthopnea Genitourinary tract
● Urinary tract infection
Neurological Locomotor system
● Epilepsy ● Osteoarthritis
● Cerebrovascular
● Inflammatory arthropathy
accidents and transient
ischemic attacks such as rheumatoid arthritis
● Psychiatric Other
disorders ● Human immunodeficiency
● Cognitive function virus
● Hepatitis
Endocrine/metabolic
● Tuberculosis
● Diabetes
● Thyroid dysfunction ● Malignancy
● Pheochromocytoma ● Allergy
● Porphyria
Past Surgical History
Previous operations? If so, what, when, and why?
Repeat procedure: surgical time and ease of operation.
Problems encountered.
Past Anesthetic History
Had anesthesia before? What operation and what type of anesthesia? Were there any
problems? Did the patient experience any post-operative nausea and vomiting?
● Family history of problems with anesthesia.
Drug History
A full drug history is required
Ask about any known allergies, both drug and non-drug allergies
Family History
Hereditary conditions: malignant hyperthermia, any known family history of problems
with anesthesia.
Social History
Smoking history, alcohol intake, and any recreational drug use
Pre-Operative Examination
The general examination: to identify any underlying
undiagnosed pathology present
The airway examination: to predict the difficulty of airway
management e.g. intubation.
Examination specific to surgery.
General Respiratory
Anemia Respiratory rate and effort
Jaundice Chest expansion and percussion note
Cyanosis Breath sounds
Nutritional status Oxygen saturation
Sources of infection (teeth, feet, leg
ulcers) Respiratory problems indications
Cardiovascular Rapid respiratory rate
Pulse Reduced air entry
Blood pressure Crepitations and rhonchi
Heart sounds
Peripheral oedema Pulmonary hypertension and right ventricular
failure indications
In Symptomatic patients Tachycardia
Cardiac failure: raised jugular Raised JVP
venous pressure (JVP), fine Tricuspid regurgitation
pulmonary crackles, gallop rhythm Hepatomegaly
Peripheral vascular disease: loss of Edematous feet
peripheral pulses, ulcerations
Valvular heart disease with
characteristic murmurs
Gastrointestinal
Abdominal masses Neurological
Consciousness level
Ascites
Cognitive function
Bowel sounds
Sensation
Hernia
Muscle power
Genitalia
Tone and reflexes
Examination specific to surgery
Clinical findings: site, side, specific imaging or investigation
findings related to the pathology for which the surgery is
proposed should be noted.
Suitability of the patient for the proposed surgical option and
vice versa should also be assessed.
Sources of potential bacteremia can compromise surgical results
especially if artificial material is implanted, such as in joint
replacement surgery or arterial grafting. Check for and treat
infections in the preoperative period, e.g. infected toes, pressure
sores, teeth and urine; screen the patients for methicillin-
resistant Staphylococcus aureus colonization.
Investigations Chest radiographs (CXR)
Cardiac failure
Severe chronic obstructive
Complete blood count
Anemia pulmonary disease (COPD)
Thrombocytopenia Acute respiratory symptoms
Sickle cell test Pulmonary cancer
Metastasis
Urea and electrolytes
Baseline renal function Effusions
Medications that affect Active pulmonary tuberculosis.
electrolyte levels
Electrocardiography (ECG) Clotting screen: deranged
history of coagulation
Iatrogenic causes
cardiovascular disease
undergoing major Inherited coagulopathies
Liver impairment
surgery
baseline for comparison
Echocardiogram (ECHO) Urinalysis
Heart murmur Urinary infection
ECG changes Biliuria
Signs or symptoms of heart Glycosuria
Blood glucose and HbA1c
Arterial blood gases
Liver function tests
Liver metabolism and synthesizing function.
Jaundice, known or suspected hepatitis, cirrhosis,
malignancy.
Group and Save (G&S) +/- cross-matching
MRSA Swabs
Nostril and perineum for MRSA colonization.
β-Human chorionic gonadotrophin
Women of child-bearing age, laboratory pregnancy test.
Specific preoperative
problems and
management
Cardiovascular Disease
Ejection fraction of 30% and less has poor prognosis
Hypertension
Blood pressure should be controlled to near 160/100mm hg
For new antihypertensive drugs a stabilization of 2 weeks should be
allowed
Diuretics are often withheld on for 24 hours prior to surgery to
prevent hypovolemia and hypokalemia.
Beta blockers should be continued since rebound hypertension might
ensue.
ACEI and ARBs are avoided for 24 hours since they might cause
hypotension.
Cont.
Ischemic heart disease and ACD
If MI develops it is recommended to wait for 3-6 months before elective
surgery
Dysrhythmia
Atrial fibrillation- β blockers, digoxin, Ca blockers should be continued
Warfarin is stopped before 5 days-aiming INR of 1.5 or less
Alternative anticoagulant is not necessary unless risk of stroke is high.
Anemia and blood transfusion
Cause of anemia and corrective actions (iron and vit supplement)
Chronic anemia is well tolerated- no need for transfusion unless in major
procedure
Respiratory Disease
Risk factors for postop pneumonia and respiratory failure
Patients with steroid tx or oxygen therapy
FEv1 of 30% or less
Management
Regular inhalation should be continued
LRTI should be treated unless the surgery is life saving
Smoking cessation before 2 months
Preoperative inspiratory muscle training
Elective surgery is postponed until correction of acute exacerbation
Gastrointestinal Disease
Nil by mouth
No solid for 6 hours and isotonic fluids within 2 hours prior to surgery…reduced
to infants
Can continue to take specific routine medications with sips of water in NBM
period
Increased risk of aspiration
Hiatus hernia
Obesity
Pregnancy
Diabetics
Management
Antacids and H2 blockers should be given
Genitourinary system
Underlying conditions leading to CKD should be stabilized
Acidosis and electrolyte disturbances should be corrected
UTI should be treated before surgery
Metabolic and Endocrine
Malnutrition
BMI < 18.5 indicates nutritional impairment
BMI < 15 associated with increased mortality
Nutritional support for minimum of 2 weeks
BMI > 35 increase risk of postoperative complications
Preventive measures for aspiration and DVT
Cont.
Diabetes Mellitus
Rapid acting and short acting drugs are stopped right after NBM
Should be first on the operating list.
Lipid- lowering medications should be started for people with high risk
of Cardiovascular complications.
IV insulin should be started for DM1 patients undergoing major surgery
Oral hypoglycemic drugs are withhold for 24 hours and resumed when
diet is started.
Exception is metformin……if there is altered renal function
The goal is to maintain BGL of 140-180 and for patients to have cardiac
surgery between 110-140
Neurologic and Psychiatric
disorders
Neuropathies and myopathies may require prolonged ventilation
If the patient has low risk of thromboembolism complications,
antiplatelet drugs should be withdrawn (7 days for aspirin and 10 for
clopidogrel)
Anticonvulsant and anti Parkinson drugs should be continued
Lithium should be stopped
Possible drug drug interactions
ASSESSMENT OF THE HIGH
RISK PATIENT
What is the predicated mortality for the patient to be
consider as HIGH RISK ?
Majority of patient enjoy recovery after surgery while
small subgroup are at higher risk of mortality
Operative mortality is expressed in terms of death during
surgery and up to 28-30 days
High risk group accounts for less than 15% of all surgical
procedures
What cause the patient to
become high risk of death?
- tissue destruction
- blood loss
-fluid shift
- change in temperature
- pain and anxiety
Assessment of high risk patient
classification of risk:- surgical vs. patient risks
1) patient risk
History of severe cardiac disease
Severe respiratory disease
Aged >70 years with limited physiological reserve
Metabolic disease
Morbid obesity
Late-stage vascular disease
Poor nutrition
B) surgical factors
Prolonged duration of surgery (>1.5 hours)
Extensive surgery
Type of surgery
Emergency surgery
bowel, gastrointestinal bleeding
Acute massive blood loss
Septicaemia
Severe multiple trauma
CASE
A 56-year-old man has been referred to the surgical outpatient
department with a right sided inguinal hernia. He has requested a day
surgical procedure. The patient has type 2 diabetes and hypertension.
He has no history of a myocardial infarction or angina. He lives in a
house with 10 stairs, which he can climb easily without shortness of
breath. He
takes metformin 500 mg tds for his diabetes and atenolol 50 mg daily
for his hypertension. He is a non-smoker and drinks fewer than 12 units
of alcohol per week. He lives with his wife who is fit and independent.
Q1. What is the patient’s ASA (American Society of
Anaesthesiologists) status?
Q2. what is the ideal ASA for the selection of day case surgery ?
Identification of the high-risk
patient
A) American Society
of
Anesthesiologist
s system
-is universal system
is widely used by
anesthesiologist for
greater number of
patient for pre
operative comorbid
conditions.
Not based on the
degree of difficulty
or severity of
operation
B) metabolic equivalents”
(METs)
The American College of Cardiology and
American Heart Association in 2007
published guidelines for the investigation
and management of cardiac risk in
patients undergoing non-cardiac surgery.
To be able to compare different protocols
and regimens in the functional assessment
of a patient, these guidelines use the
concept of “metabolic equivalents” (METs)
to stratify different levels of function. The
resting oxygen consumption (VO2) of
a 70-kg, 40 year-old man is 3.5
ml/kg/min and is equal to 1 MET.
Excellent functional capacity is defined by
a score of >10 METs. Good function is 7-10
METs, moderate is 4-7 METs, and poor
function is <4 METs. Poor functional
capacity (i.e. reduced METs) puts the
patient into a high-risk category
C) Cardio pulmonary exercise
testing(CPET)
The oxygen (O2) consumption
and carbon dioxide (CO2)
production of the patient are
measured while they undergo a
10 minute period of
incrementally demanding
exercise
The ‘anaerobic threshold’ (AT) is
the O2 consumption in mL/kg
per minute above which a
sustained increase in blood
lactate concentration occurs.
Peak oxygen consumption (VO2 )
is also measured
D) Revised cardiac risk index ( RCRI)
E) POSSUM score
Another widely used http://www.riskprediction.org.uk/pp-index.php
scoring system is
POSSUM for predicting all-cause
mortality in postoperative critical care
patients, as well as non-cardiac
morbidity.
POSSUM can only be used
postoperatively and is better for some
surgery e.g. colorectal, vascular
A number of websites provide POSSUM
and P-POSSUM calculators
http://www.riskprediction.org.uk/pp-
index.php
Management Of High-Risk Surgical
Patients
Goal-Directed Therapy : modifying the cardiovascular
parameters of high risk patients to reach predetermined hemodynamic goals, in
order to improve tissue oxygen flux.
Improved survival, reduced complications and shorter length of hospital stay
have been shown when goal-directed therapy is used to increase cardiac index
(CI) and oxygen delivery index (DO2i) to specifically targeted levels at any point
in the perioperative period.
A) oxygen delivery (DO2)
The relationship between global oxygen delivery
(DO2), cardiac output and arterial oxygen
content is expressed in the following equation:
DO2 (ml/minute) = Cardiac Output (CO)
(L/minute) x Arterial oxygen content (ml/L)
(CaO2)
B)The oxygen extraction ratio (OER)
It is the ratio of oxygen consumption in a given organ (VO2) to
oxygen delivery (DO2).
In periods of physiological stress such as surgery, where DO2 falls,
the OER increases as tissues extract more oxygen from the remaining
blood flow.
A raised OER can be used a surrogate marker of inadequate oxygen
delivery. In practical terms this means measuring the central venous
oxygen saturation (ScvO2)
A ScvO2 <70% implies that oxygen extraction is increased, and that
the OER is high.
Reduced oxygen delivery (DO2), oxygen consumption (VO2), and reduced
central venous oxygen saturations (ScvO2) are all associated with
postoperative complications and increased mortality in high-risk patients.
Fundamental to the management of high-risk surgical patients, therefore, is
the maintenance of oxygen delivery to the body’s tissues.
Performing goal-directed
therapy
The targets used in goal-directed therapy were originally derived from observation
of the physiological parameters of survivors of high-risk surgery made by
Shoemaker and colleagues in 1988. These included cardiac index >/= 4.5
l/min/m2, oxygen delivery index >/= 600 ml/minute/m2, and tissue oxygen
consumption index (VO2i)>170 ml/minute/m2. These values, which were higher
than those observed in the same patients at rest preoperatively, became known as
“supranormal” values.
1. Routine patient management; optimization of hemoglobin level and
maintenance of oxygenation and coronary artery perfusion pressure.
2. Ensure optimal circulating volume ; optimization with fluid boluses and
Using drugs to increase cardiac output in an adequately filled patient(commonly
used drugs include dobutamine and dopexamine)
3. Maintenance of hemodynamic parameters at supranormal levels; using
further fluid boluses in response to a falling stroke volume, and infusion of low-
dose dopexamine
Summary
Preoperative assessment
in in emergency surgery
In emergency surgery the principles of preoperative assessment should be the
same as in elective surgery, except that the opportunity to optimise the condition
is limited by time and facilities available .
Medical assessment and treatments should be started according to ATLS guide line
even if there is no time to complete them before the start of the surgical
procedure.
Airway assessment
Ability to intubate the trachea and oxygenate the patient are basic and crucial skills of the anaesthetist.
The ease or difficulty in performing airway manoeuvres can be predicted by the Samsoon and Young
modified Mallampati test.
The higher the grade, the higher the risk in obtaining and securing an airway.
Look for loose teeth, obvious tumours, scars, infections, obesity, thickness of the neck, etc., which will
indicate difficulty in obtaining the airway.
The size of the tongue in relation to the oral cavity can be graded by using the
Mallampati classification.
Its performed with the patient sitting and the head in neutral position, the mouth
opened as wide as possible, the tongue protruded maximally.
Airway assessment (Samsoon and Young
modified Mallampati test).
Fauces, pillars, soft palate and Grade
uvula seen 1
Fauces, soft palate with some part of Grade 2
uvula seen
Soft palate seen Grade 3
Hard palate only seen Grade 4
Informed consent
Is a process by which a subject voluntarily confirms his or her willingness to participate
in a particular clinical procedure.
It should obtained from competent individual who can understand information and use
it to make disicion
Clinical notes should be presented in a logical and economical manner.
Investigations and a management plan should be clearly listed for action.
should be written and recorded on a form
The key principles of consent and how the discussion should:
give the patient the information required to make a decision
explain all reasonable treatment options
Explain the purpose of a proposed investigation or treatment
Describe the likely benefits and probability of success
Describe any possible adverse effects
Ask the patient how much they understand about their diagnosis and proposed
Questions
1. A 65 years old female, known diabetic patient for the past 20 years, is
on triage to have open heart surgery.
What should be done in the preoperative assessment?
What are the possible problems and their management?
Can we consider the patient as high risk? If so why?
2. A 25 year old man had group fight and come to the ER with splenic
rapture.
When does the preoperative assessment begin?
What should be assessed in the emergency surgery?
Reference
Bailey & Love’s Short Practice of
Surgery, 27th ed. Arnold, London
Sabiston Textbook of Surgery The
Biological Basis of Modern Surgical
Practice, 20th Edition (2016) [PDF]
[UnitedVRG]
