PREANESTHESIA EVALUATIONthe process of clinical assessment that precedes the delivery of anesthesia care for surgery and
for non-surgical procedures
Can or should the patient’s physical or mental Can or should the patient’s physical or mental condition be improved before surgery?condition be improved before surgery?
Does the patient have any health problems or Does the patient have any health problems or use any medications that could use any medications that could unexpectedly influence perioperative unexpectedly influence perioperative events?events?
GOALSGOALS of of preoperative preoperative evaluationevaluation
1.1. To reduce the morbidity of surgeryTo reduce the morbidity of surgery2.2. To increase the quality but decrease the cost To increase the quality but decrease the cost
of perioperative careof perioperative care3.3. To educate the patient about anesthesia, To educate the patient about anesthesia,
perioperative care, and pain treatmentsperioperative care, and pain treatments4.4. To reduce anxiety and facilitate optimal To reduce anxiety and facilitate optimal
recoveryrecovery
Routine Preoperative EvaluationHistoryPhysical examinationLaboratory evaluationASA physical status classificationObtaining informed consentFormulation of anesthetic plan
Routine Preoperative anesthetic evaluationRoutine Preoperative anesthetic evaluation
Current problemCurrent problemOther known problemsOther known problemsMedication historyMedication history
AllergiesAllergiesDrug intolerancesDrug intolerancesPresent therapy (prescription, nonprescription)Present therapy (prescription, nonprescription)Nontherapeutic (alcohol, tobacco)Nontherapeutic (alcohol, tobacco)IllicitIllicit
Previous anesthetics, surgery, and obstetric deliveriesPrevious anesthetics, surgery, and obstetric deliveriesFamily historyFamily historyReview of organ systemsReview of organ systems
GeneralGeneral NeurologicNeurologicRespiratoryRespiratory EndocrineEndocrineCardiovascularCardiovascular PsychiatricPsychiatricRenalRenal OrthopedicOrthopedicGastrointestinalGastrointestinal DermatologicDermatologicHematologicHematologic
Last oral intakeLast oral intake
HistoryHistory
Routine Preoperative anesthetic evaluationRoutine Preoperative anesthetic evaluation
Current problem Current problem determine surgical diagnosisdetermine surgical diagnosisindications for planned surgical procedureindications for planned surgical procedureexact nature of comtemplated surgical exact nature of comtemplated surgical procedureprocedure
Other known problemsOther known problemsMedication historyMedication history
AllergiesAllergiesDrug intolerancesDrug intolerancesPresent therapy (prescription, nonprescription)Present therapy (prescription, nonprescription)Nontherapeutic (alcohol, tobacco)Nontherapeutic (alcohol, tobacco)IllicitIllicit
Previous anesthetics, surgery, and obstetric deliveriesPrevious anesthetics, surgery, and obstetric deliveriesFamily historyFamily historyReview of organ systemsReview of organ systems
GeneralGeneral NeurologicNeurologicRespiratoryRespiratory EndocrineEndocrineCardiovascularCardiovascular PsychiatricPsychiatricRenalRenal OrthopedicOrthopedicGastrointestinalGastrointestinal DermatologicDermatologicHematologicHematologic
Last oral intakeLast oral intake
HistorHistoryy
Routine Preoperative anesthetic evaluationRoutine Preoperative anesthetic evaluation
Current problemCurrent problem
Other known problemsOther known problems
Medication historyMedication historyAllergiesAllergiesDrug intolerancesDrug intolerancesPresent therapy (prescription, nonprescription)Present therapy (prescription, nonprescription)Nontherapeutic (alcohol, tobacco)Nontherapeutic (alcohol, tobacco)IllicitIllicit
Previous anesthetics, surgery, and obstetric deliveriesPrevious anesthetics, surgery, and obstetric deliveriesFamily historyFamily historyReview of organ systemsReview of organ systems
GeneralGeneral NeurologicNeurologicRespiratoryRespiratory EndocrineEndocrineCardiovascularCardiovascular PsychiatricPsychiatricRenalRenal OrthopedicOrthopedicGastrointestinalGastrointestinal DermatologicDermatologicHematologicHematologic
Last oral intakeLast oral intake
HistorHistoryy
Routine Preoperative anesthetic evaluationRoutine Preoperative anesthetic evaluation
Current problemCurrent problemOther known problemsOther known problems
Medication historyMedication historyAllergiesAllergiesDrug intolerancesDrug intolerancesPresent therapy (prescription, nonprescription)Present therapy (prescription, nonprescription)Nontherapeutic (alcohol, tobacco)Nontherapeutic (alcohol, tobacco)IllicitIllicit
Previous anesthetics, surgery, and obstetric deliveriesPrevious anesthetics, surgery, and obstetric deliveriesFamily historyFamily historyReview of organ systemsReview of organ systems
GeneralGeneral NeurologicNeurologicRespiratoryRespiratory EndocrineEndocrineCardiovascularCardiovascular PsychiatricPsychiatricRenalRenal OrthopedicOrthopedicGastrointestinalGastrointestinal DermatologicDermatologicHematologicHematologic
Last oral intakeLast oral intake
HistorHistoryy
Routine Preoperative anesthetic evaluationRoutine Preoperative anesthetic evaluation
Current problemCurrent problemOther known problemsOther known problemsMedication historyMedication history
AllergiesAllergiesDrug intolerancesDrug intolerancesPresent therapy (prescription, nonprescription)Present therapy (prescription, nonprescription)Nontherapeutic (alcohol, tobacco)Nontherapeutic (alcohol, tobacco)IllicitIllicit
Previous anesthetics, surgery, and Previous anesthetics, surgery, and obstetric deliveriesobstetric deliveries
Family historyFamily historyReview of organ systemsReview of organ systems
GeneralGeneral NeurologicNeurologicRespiratoryRespiratory EndocrineEndocrineCardiovascularCardiovascular PsychiatricPsychiatricRenalRenal OrthopedicOrthopedicGastrointestinalGastrointestinal DermatologicDermatologicHematologicHematologic
Last oral intakeLast oral intake
HistorHistoryy
Routine Preoperative anesthetic evaluationRoutine Preoperative anesthetic evaluation
Current problemCurrent problemOther known problemsOther known problemsMedication historyMedication history
AllergiesAllergiesDrug intolerancesDrug intolerancesPresent therapy (prescription, nonprescription)Present therapy (prescription, nonprescription)Nontherapeutic (alcohol, tobacco)Nontherapeutic (alcohol, tobacco)IllicitIllicit
Previous anesthetics, surgery, and obstetric deliveriesPrevious anesthetics, surgery, and obstetric deliveries
Family historyFamily history
Review of organ systemsReview of organ systemsGeneralGeneral NeurologicNeurologicRespiratoryRespiratory EndocrineEndocrineCardiovascularCardiovascular PsychiatricPsychiatricRenalRenal OrthopedicOrthopedicGastrointestinalGastrointestinal DermatologicDermatologicHematologicHematologic
Last oral intakeLast oral intake
HistorHistoryy
Routine Preoperative anesthetic evaluationRoutine Preoperative anesthetic evaluation
Current problemCurrent problemOther known problemsOther known problemsMedication historyMedication history
AllergiesAllergiesDrug intolerancesDrug intolerancesPresent therapy (prescription, nonprescription)Present therapy (prescription, nonprescription)Nontherapeutic (alcohol, tobacco)Nontherapeutic (alcohol, tobacco)IllicitIllicit
Previous anesthetics, surgery, and obstetric deliveriesPrevious anesthetics, surgery, and obstetric deliveriesFamily historyFamily history
Review of organ systemsReview of organ systemsGeneralGeneral NeurologicNeurologicRespiratoryRespiratory EndocrineEndocrineCardiovascularCardiovascular PsychiatricPsychiatricRenalRenal OrthopedicOrthopedicGastrointestinalGastrointestinal DermatologicDermatologicHematologicHematologic
Last oral intakeLast oral intake
HistoryHistory
Routine Preoperative anesthetic evaluationRoutine Preoperative anesthetic evaluation
Current problemCurrent problemOther known problemsOther known problemsMedication historyMedication history
AllergiesAllergiesDrug intolerancesDrug intolerancesPresent therapy (prescription, nonprescription)Present therapy (prescription, nonprescription)Nontherapeutic (alcohol, tobacco)Nontherapeutic (alcohol, tobacco)IllicitIllicit
Previous anesthetics, surgery, and obstetric deliveriesPrevious anesthetics, surgery, and obstetric deliveriesFamily historyFamily historyReview of organ systemsReview of organ systems
GeneralGeneral NeurologicNeurologicRespiratoryRespiratory EndocrineEndocrineCardiovascularCardiovascular PsychiatricPsychiatricRenalRenal OrthopedicOrthopedicGastrointestinalGastrointestinal DermatologicDermatologicHematologicHematologic
Last oral intakeLast oral intake-- -- risk for aspiration of stomach contents when patient risk for aspiration of stomach contents when patient
is rendered unconscious by anestheticsis rendered unconscious by anesthetics-- ‘NPO’ for at least 6 hrs prior to elective surgery-- ‘NPO’ for at least 6 hrs prior to elective surgery-- delayed gastric emptying time expected in -- delayed gastric emptying time expected in
pregnancy, obesity, diabetics with autonomic pregnancy, obesity, diabetics with autonomic dysfunctiondysfunction
HistorHistoryy
Physical examinationPhysical examination
Vital signsVital signsAirwayAirwayHeartHeartLungsLungsExtremitiesExtremitiesNeurologic examinationNeurologic examination
Routine Preoperative anesthetic evaluationRoutine Preoperative anesthetic evaluation
Physical examinationPhysical examination
Vital signsVital signsAirwayAirwayHeartHeartLungsLungsExtremitiesExtremitiesNeurologic examinationNeurologic examination
Routine Preoperative anesthetic evaluationRoutine Preoperative anesthetic evaluation
Physical examinationPhysical examinationVital signsVital signsAirwayAirwayHeartHeartLungsLungsExtremitiesExtremitiesNeurologic examinationNeurologic examination
Routine Preoperative anesthetic evaluationRoutine Preoperative anesthetic evaluation
Physical examinationPhysical examination
Vital signsVital signsAirwayAirwayHeartHeartLungsLungsExtremitiesExtremitiesNeurologic examinationNeurologic examination
Routine Preoperative anesthetic evaluationRoutine Preoperative anesthetic evaluation
PREOPERATIVE TESTSMay be indicated for various purposes, including but not limited
to:
1)discovery or identification of a disease or disorder which may affect perioperative anesthetic care
2) verification or assessment of an already known disease, disorder, medical or alternative therapy
which may affect perioperative anesthetic care3) formulation of specific plans and alternatives for
perioperative anesthetic care.
Routine battery of laboratory tests vs
Problem directed, selective determination of laboratory tests
Routine Tests
A test ordered in the absence of a specific clinical indication or purpose
Indicated TestsA test that is ordered for a specific clinical indication or
purpose
ASA Practice Advisory for Preanesthesia Evaluation
A Report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation
PRACTICE ADVISORIESSystematically developed reports that are intended to
assist decision-making in areas of patient care where scientific evidence is insufficient to develop an evidence-based model
PRACTICE ADVISORIESIn contrast to STANDARDS or GUIDELINES,practice
advisories are not supported by sufficient numbers of controlled studies.
They may be adopted, modified or rejected according to clinical needs and constraints
ELECTROCARDIOGRAMECG abnormalities may be higher in older patients and in
patients with multiple cardiac risk factors
No consensus regarding a minimum age for obtaining a preanesthesia ECG
ELECTROCARDIOGRAMImportant clinical characteristics that may warrant
preop ECG: cardiocirculatory disease respiratory disease type or invasiveness of surgery
AMERICAN HEART ASSOCIATION/AMERICAN COLLEGE OF CARDIOLOGYGUIDELINES FOR ELECTROCARDIOGRAPHY: ECG abnormalities rise exponentially with age. Patients who have no apparent heart disease but are older
than 40 should have a preop ECG.
Preanesthesia Cardiac Evaluation Other than an ECGStress test, Echocardiogram, Radionucleotide imaging,
cardiac catheterization
Clinical characteristics to consider: cardiovascular risk factors type of surgery
Chest X-rayClinical chracteristics to consider: smoking recent URTI COPD cardiac disease
Preanesthesia Pulmonary Evaluation (other than X-ray)Pulmonary function tests, spirometry, pulse
oximetry, arterial blood gas
Clinical considerations: type and invasiveness of the sx procedure interval from prior evaluation treated or symptomatic asthma symptomatic COPD scoliosis with restrictive function
IS THERE AN OPTIMAL PREOPERATIVE Hb/Hct?10g/dl rule??? There are no randomized prospective studies defining a
specific minimum Hb conc as a risk factor for anesthesia and surgery.
Came from older, anecdotal case series andn cohort studies
Preanesthesia Hemoglobin and HematocritROUTINE Hb, Hct is not advisable
Clinical considerations: type and invasiveness of sx procedure liver disease extremes of age history of anemia, bleeding, other hematologic disorders
Clinical considerations for preop Hb determinationPatients with significant cardiac and pulmonary disease
will have a limited tolerance for perioperative anemia.
The decision for perioperative transfusion should be based on preop Hb conc, anticipated blood loss, and cardiorespiratory status
Preanesthesia Coagulation StudiesINR, PT, PTT, Platelets
Clinical considerations: bleeding disorders renal dysfunction liver dysfunction type and invasiveness of procedure
Routine coagulation tests prior to regional anesthesia?
The Task Force believes that there is not enough data to comment on the advisability of coagulation tests before regional anesthesia.
Preanesthesia Serum ChemistriesSerum electrolytes, glucose, renal and liver function
tests
Clinical considerations: perioperative therapies endocrine disorders risk of renal and liver dysfunction use of certain medications or alternative therapies
Preanesthesia UrinalysisIt is not indicated except for specific procedures (e.g. prosthesis implantation, urologic
procedures) and when urinary tract symptoms are present
Preanesthesia Pregnancy TestingBecause history and PE may be insufficient for
identification of early pregnancy, pregnancy testing must be OFFERED but not required for all females of childbearing age
SHOULD ALL ANTIHYPERTENSIVE AGENTS BE CONTINUED BEFORE SURGERY
BETA BLOCKERS and CLONIDINE: sequelae of abrupt discontinuation: withdrawal syndrome: rebound hpn advantage of continuation: cardiovascular risk reduction
recommendation: continue
SHOULD ALL ANTIHYPERTENSIVE AGENTS BE CONTINUED BEFORE SURGERYCalcium channel blockers: no withdrawal sequelae cardiovascular risk reduction perioperatively recommendation: continue
SHOULD ALL ANTIHYPERTENSIVE AGENTS BE CONTINUED BEFORE SURGERYACE inhibitors increased risk of intraoperative hypotension
recommendation: discontinue at least 10 hrs before anesthesia and surgery
Preoperative physical status classification Preoperative physical status classification of patients according to the American of patients according to the American
Society of AnesthesiologistsSociety of AnesthesiologistsClassClass DefinitionDefinition
11 A normal healthy patient.A normal healthy patient.
22A patient with mild systemic disease and no functional A patient with mild systemic disease and no functional limitations.limitations.
33A patient with moderate to severe systemic disease that results A patient with moderate to severe systemic disease that results in some function limitation.in some function limitation.
44A patient with severe systemic disease that is a constant threat A patient with severe systemic disease that is a constant threat to life and functionally incapacitating.to life and functionally incapacitating.
55A moribund patient who is not expected to survive 24 hours A moribund patient who is not expected to survive 24 hours with or without surgery.with or without surgery.
66 A brain-dead patient whose organs are being harvested.A brain-dead patient whose organs are being harvested.
EEIf the procedure is an emergency, the physical status is If the procedure is an emergency, the physical status is followed by “E” (e.g. “2E”)followed by “E” (e.g. “2E”)
ClassClass Mortality RateMortality Rate
11 0.06-0.08%
22 0.27-04%
33 1.8-4.3%
44 7.8-23%
55 9.4-51%
Preoperative physical status Preoperative physical status classification of patients according to the classification of patients according to the
American Society of AnesthesiologistsAmerican Society of Anesthesiologists
Informed Informed consentconsent
Preoperative visit culminates in giving the patient a Preoperative visit culminates in giving the patient a reasonable explanation of the options available for reasonable explanation of the options available for anesthetic managementanesthetic management
Informed consentInformed consent
written consent is advisable for written consent is advisable for medicolegal purposesmedicolegal purposes
any procedure any procedure performed without performed without patient’s consentpatient’s consent
physician liable physician liable for assault and for assault and batterybattery
How much of the risks How much of the risks should we tell?should we tell?
Only those that are Only those that are realistic risksrealistic risks in similar in similar patients with similar problemspatients with similar problems
It is advisable to inform the patient that some It is advisable to inform the patient that some complicationscomplications may be life threatening may be life threatening
The anesthetic planThe anesthetic planPremedicationPremedicationType of anesthesiaType of anesthesia
GeneralGeneralAirway managementAirway managementInductionInductionMaintenanceMaintenanceMuscle relaxationMuscle relaxation
Local or regional anesthesiaLocal or regional anesthesiaTechniqueTechniqueAgentsAgents
Monitored anesthesia careMonitored anesthesia careSupplemental oxygenSupplemental oxygenSedationSedation
Intraoperative managementIntraoperative managementMonitoringMonitoringPositioningPositioningFluid managementFluid managementSpecial techniquesSpecial techniques
Postoperative managementPostoperative managementPain controlPain controlIntensive careIntensive care
Postoperative ventilationPostoperative ventilationHemodynamic monitoringHemodynamic monitoring
Good day!Good day!