Preoperative assessment surgery mbbs

1. Dr Ritesh Kumar
Asst. Prof,
Deptt of Surgery

2. PATIENT ASSESSMENT
 Correction of anaemia, better diabetes control, preoperative
exercises and better nutrition leads to better patient outcomes
and fewer postoperative complications
 Based on population statistics, associated comorbidities and the
type of surgery, one can estimate risks for an individual
undergoing surgery
 Patient assessment can be done by -
 History taking
 Examination
 Investigations

3. HISTORY TAKING
 Each organ system problem should be noted with dates,
aetiology and treatment delivered
 Patients with recent chest infections should be assessed for
anaesthetic risks and postoperative surgical infection
 Inability to achieve four metabolic equivalents, e.g. climbing a
flight of stairs, increases cardiac risk after major surgery
 History of past surgery and anaesthesia can reveal the problems
one may face during current hospitalisation (e.g. intra-
abdominal adhesions for planned laparoscopic surgery)
 Check for allergies and risk factors for deep vein thrombosis
(DVT)

4. Past history

5. Past History

6. EXAMINATION
 Patient should be given clear explanation of the
examination undertaken and be kept as comfortable as
possible
 Includes 4 parts –
 General
 Surgery related
 Systemic
 Specific – e.g. suitability for positioning during surgery

8. Examination specific to surgery
 At preoperative assessment, the clinical findings, site, side,
specific imaging or investigation findings related to the
pathology for which the surgery is proposed should be noted
 Assess the suitability of the patient for the proposed surgical
option
 Sources of potential bacteremia can compromise surgical results
especially if artificial material is implanted, such as in joint
replacement surgery
 Check for and treat infections in the preoperative period, e.g.
infected toes, pressure sores, teeth and urine

9. INVESTIGATIONS
 Full blood count –
 Needed for major operations, in the elderly and in those with
anaemia or pathology with ongoing blood loss
 Urea and electrolytes –
 needed before all major operations, in patients over 65 years
of age especially with cardiovascular, renal and endocrine
disease
 in those on medications that affect electrolyte levels, e.g.
steroids, diuretics, digoxin

10. Investigations contd..
 Electrocardiography (ECG)
 required for those patients over 65 years of age and
symptomatic patients with a history of rheumatic fever,
diabetes, cardiovascular, renal and cerebrovascular
disease
 Chest radiograph
 patients with cardiac failure, severe chronic obstructive
pulmonary disease (COPD), acute respiratory
symptoms, pulmonary cancer, metastasis or effusions or
those at risk of active pulmonary tuberculosis
 Clotting screen
 history suggestive of a bleeding diathesis, liver disease,
eclampsia, cholestasis or has a family history of bleeding
disorder, or is on anticoagulant agents

11. Investigations contd..
 Urinalysis
 should be performed on all patients to detect urinary
infection, biliuria, glycosuria
 Blood glucose and HbA1c
 Poor control of diabetes can lead to perioperative infection
and slow recovery
 Liver function tests
 indicated in patients with jaundice, known or suspected
hepatitis, cirrhosis, malignancy or in patients with poor
nutritional status
 Other investigations
 Specialist radiological views and recent imaging are
sometimes required

12. AIRWAY ASSESSMENT
 The ease or difficulty encountered when performing
airway manoeuvres can be predicted by simple
examination findings of full mouth opening (modified
Mallampati class), jaw protrusion, neck movement and
thyromental distance
 Also look for loose teeth, obvious tumours, scars,
infections, obesity, thickness of the neck, etc., which will
indicate difficulty in visualising the airway

13. Modified Mallampati class –
Anaesthetist sits in front of the patient and asked to open their mouth
and protrude the tongue
The higher the grade, the higher the risk in obtaining and securing an
airway

15. ASSESSMENT OF THE HIGH RISK
PATIENT
 By identifying high-risk patients in the preoperative
phase and planning their perioperative management,
morbidity and mortality can be reduced
 Patients who have a predicted mortality ≥5% should be
considered as ‘high risk’
 After surgery tissue destruction, blood loss, fluid
shifts, changes in temperature, pain and anxiety result
in increased demands for oxygen delivery to the tissues
 Patients who are unable to meet these demands are at
a higher risk of myocardial ischaemia or stroke

16. Factors contributing to risk

17. Management of risk

18. Identification of high-risk patient

20.  POSSUM score –
 Physiologic and Operative Severity Score for the
enUmeration of Mortality and Morbidity
 Used to predict all-cause mortality in postoperative
critical care patients as well as non-cardiac morbidity
 Cardiopulmonary exercise testing
 Screening tool to identify high-risk patients
 The oxygen consumption and carbon dioxide production
of the patient are measured while they undergo a 10
minute period of exercise up to their maximally
tolerated level
 Principle - when a subject’s delivery of oxygento active
tissues becomes inadequate, anaerobic metabolism
begins; lactate is buffered by bicarbonate and the
resulting Carbon dioxideincreases out of proportion to
increase in physical difficulty and oxygenconsumption

21. Optimisation of the high-risk
patient
 Simple measures include
 Stop smoking (maximal benefit only seen if stopped for
8 weeks prior to surgery)
 Reducing alcohol intake
 Losing weight
 Improving nutrition and haemoglobin levels
 Review of medication
 Multidisciplinary team approach

22. Management of specific co-morbid
factors
 Ischaemic heart disease
 can be precipitated by hypotension, tachycardia and
procoagulant states
 Management –
 involve further investigations
 to postpone non-cardiac surgery for 3–6 months after an MI
 Some patients may require preoperative revascularisation, using
either a coronary artery bypass grafting (CABG) or percutaneous
coronary intervention (PCI) with a stent or angioplasty

23.  Minimising myocardial ischaemia
 Use of anaesthesia that avoid tachycardia, systolic
hypertension and diastolic hypotension
 Blood loss must be accurately monitored and haemoglobin
maintained
 Perioperative use of β-blockers
 Troponin testing allows early diagnosis of perioperative MIs
 Admission to HDU should be considered for patients with
IHD and supplemental oxygen therapy continued for 3–4 days

24.  Cardiac failure
 Those with ejection fractions of less than 35%, and in
whom the failure is undiagnosed are at the highest risk
 surgery should be delayed for investigations such as an
echocardiogram and/or for optimisation of medical
therapy
 β-blockers and probably ACE inhibitors should be
continued
 Anaesthesia should ensure minimal myocardial
depression and change in afterload during surgery
 Arrhythmias must be rapidly brought under control,
particularly AF, and correcting any electrolyte imbalance

25.  Respiratory failure
 Respiratory depressant effect of residual anaesthetic agents, the
patient’s limited mobility and pain from surgery causes
atelectasis and predisposes patients to postoperative respiratory
infection
 Other complications including bronchospasm, pneumothorax
and acute respiratory distress syndrome (ARDS)
 Management –
 Preoperatively, bronchodilator therapy will be required in those with
reversible obstructive airway disease and steroids may need to be
started or increased
 Nutritional status should be optimised and albumin levels corrected
 Deep breathing exercises or incentive spirometry should be considered
for patients at increased risk
 General anaesthesia is associated with more respiratory complications
and so regional techniques should be considered
 Delaying extubation until analgesia, hydration and acid–base status
have been corrected

26.  Other comorbidities
 Acute kidney injury, chronic kidney disease, diabetes,
peripheral vascular disease and liver dysfunction need to
be optimised
 Sepsis
 Early resuscitative measures in sepsis include
 administering broad spectrum antibiotics
 treating hypotension, hypovolemia and elevated lactate levels
with appropriate intravenous fluids
 Deal with the source of sepsis as early as possible

27. Thanks