preanaesthetic/pre surgical evaluation

2.  AIM
 PURPOSE OF MEETING OF PATIENT AND ANAESTHESIST
 IMPORTANT FUNCTION OF PREOPERATIVE EVALUATION ARE
 General Health Assessment
 What Are the Different Methods of Surgery
 According to ASA
 Laboratory work up
 The normal AND ABNORMAL blood picture
 INR ,PT, PTT and ISI
 Electrolyte and creatinine
 CVS assesment
 Exercise tolerance
 Chest radiographs
 Elecro cardiogram
 Pulmonary function test
 Diabetes mellitus
 Steroids
 Management of patient of anticoagulant
 Conclusion
 bibliography

3.  THE ULTIMATE GOAL OF PREOPERATIVE MEDICAL
ASSESMENT OF PATIENTS ARE TO REDUCE THE MORBIDITY OF
SURGERY, TO INCREASE QUALITY BUT DECREASE COST OF
POST OPERATIVE CARE, AND TO RETURN THE PATIENT TO
DESIRABLE FUNCTIONING AS QUICKLY AS POSSIBLE

4.  AS A CONSULTANT, THE QUESTION ASKED IS: “FOR THIS
PATIENT, ARE THE MEDICAL CONDITIONS AS GOOD AS THEY
CAN BE?”

5.  PURPOSE
 1. Documentationof the condition(s)for which surgery is needed.
 2. Assessment of the patient’soverall healthstatus.
 3. Uncoveringof hidden conditionsthat could cause problems both during and after surgery.
 4. Perioperative riskdetermination.
 5. Optimizationof the patient’smedical conditionin order to reduce the patient’ssurgical and
anestheticperioperativemorbidityor mortality.

6.  6. Development of an appropriateperioperativecare Plan.
 7. Educationof the patient about surgery, anesthesia, intraoperativecare and postoperative
pain treatments in the hope of reducing anxiety andfacilitating
 recovery.
 8. Reductionof costs, shortening ofhospital stay, reduction of cancellationsand increase of
patient satisfaction.

7. 1. OPTIMIZING PATIENT HEALTH BEFORE SURGERY
2. MOST APPROPRIATE PERIOPERATIVE MANAGEMENT

8.  The history- include a past and current medical history,
 a surgical history,
 a family history,
 a social history (use of tobacco, alcohol and illegaldrugs),
 a historyof allergies
 current and recent drug therapy,
 unusual reactionsor responses to drugs and any problems or complicationsassociatedwith previous anesthetics.
Systemic history-
• look for undiagnosed chronic disease
• Inadequately controlled chronic disease

9.  Open surgery
 Minimally invasivesurgery

10. 1..Class A- minimally invasive-
° less potentialto disrupt normal physiology.
° Rarelyassociatedwith morbidityassociatedwith anesthesia
° Rarelyrequire blood administration,invasive monitoring,or postoperative management in intensive care serting
2.. Class B-moderately invasive
° modest potentialto disruptnormal physiology
° may require blood administration
° Invasive monitoringor monitoringin intensive care

11. 3.. Class 3 highly invasive –
 Significant disrutption of normal physiology
 Almost always require blood administration
 Invasive monitoring or post operative management in critical care setting

15.  Complete blood count:-
 Red blood cells, which carry oxygen
 White blood cells, which fight infection
 Hemoglobin, the oxygen-carrying protein in red blood cells
 Hematocrit, the proportion of red blood cells to the fluid
component, or plasma, in your blood
 Platelets, which help with blood clotting

16.  Red blood cell countMale: 4.32-5.72 trillion cells/L*
 (4.32-5.72 million cells/mcL**)
 Female : 3.90-5.03 trillion cells/L
 (3.90-5.03 million cells/mcL)
 Hemoglobin
 Male: 13.5-17.5 grams/dL***
 (135-175 grams/L)
 Female: 12.0-15.5 grams/dL
 (120-155 grams/L)
 Hematocrit
 Male: 38.8-50.0 percent
 Female: 34.9-44.5 percent
 White blood cell count
 3.5-10.5 billion cells/L
 (3,500 to 10,500 cells/mcL)
 Platelet count
 150-450 billion/L
 (150,000 to 450,000/mcL**)

19.  A prothrombin time (PT) is a test used to help detect and diagnose a bleeding
disorder or excessive clotting disorder;
 The international normalized ratio (INR) is calculated from a PT result and is
used to monitor how well the blood-thinning medication (anticoagulant)
warfarin is working to prevent blood clots.
 The partial prothrombin time (PTT) test evaluates those protein factors that are
part of the intrinsic and common pathways


20.  For calculating the international normalized ratio, a patient's prothrombin time is
divided by the mean normal prothrombin time. This ratio is raised to a power
called the international sensitivity index
 The reference range for prothrombin time is 9.5-13.5 seconds.
 The reference range for international normalized ratio (INR) is less than 1.3
 However, the normal range is highly variable and dependent on the laboratory
performing the test

21.  The prothrombin time is a measure of the integrity of the extrinsic and
final common pathways of the coagulation cascade. This consists of
tissue factor and factors VII, II (prothrombin), V, X, and fibrinogen.
The test is performed by adding calcium and thromboplastin, an
activator of the extrinsic pathway, to the blood sample then measuring
the time (in seconds) required for fibrin clot formation.

23.  ELECTROLYTES ARE MINERALS IN YOUR BLOOD AND OTHER BODY FLUIDS
THAT CARRY AN ELECTRIC CHARGE
 COMMON ELECTROLYTES INCLUDE:
 Chloride: 95-105 mmol/L
 Creatinine: 0.8-1.3 mg/dL
 Glucose: 65-110 mg/dL
 Inorganic phosphorous: 1-1.5 mmol/L
 Ionized calcium: 1.03-1.23 mmol/L
 Magnesium: 1.5-2 mEq/L
 Potassium: 3.5-5 mmol/L
 Sodium: 135-145 mmol/L
 Total calcium: 2-2.6 mmol/L
 Urea: 1.2-3 mmol/L
 Uric acid: 0.18-0.48 mmol/L

25.  American college of cardiology and american heart association published guidelines for CVS
evaluation for non cardiac surgeries

26.  It is usually evaluatedby the estimatedenergy requirement for various activitiesand graded in
metabolicequivalents(MET) on a scale definedby the Duke Activity Status Index
 One MET represents the oxygen consumptionof a resting adult (3.5 ml/kg/min).

27.  Includes
a. Chest radiographs :-

30.  Electrocardiography (ECG or EKG*) is the process of recording the electrical activity of the heart
over a period of time using electrodes placed on the skin

31.  10 lead
 5 lead ecg
 3 lead ecg

32.  Pulmonary function tests(PFTs) are a group of tests that measure how well your lungs work. Thisincludes how
well you’re able to breathe and how effective your lungs are able to bring oxygen to the rest of your body

35.  Procedure-related risk factors: primarily based on how close the
surgery is to the diaphragm (i.e. upper abdominal and thoracic
surgery are the highest risk procedures).
 Length of surgery (> 3 hours) and general anesthesia (vs. epidural
or spinal).
 Emergency surgery.
 Underlying chronic pulmonary disease or symptoms of respiratory
infection.
 Smoking.
 Age >60 years.
 Obesity.
 Presence of obstructive sleep apnea.
 Poor exercise tolerance or poor general health status.

38.  it is important to remember that patient is more likely to be harmed by neglect of the
long term complications of diabetes than from the short term control of blood
glucose levels
 diabetic patient who needs elective surgery should be carefully assessed
preoperatively for symptoms and signs of peripheral vascular, cerebrovascular and
coronary disease

39.  Adequate control of blood glucose concentration (< 180 mg/dL) must
be established preoperatively and maintained until oral feeding is
resumed after operation.
 Oral hypoglycemic agents are withheld the day of surgery for an agent
with a short half-life and up to 48 h preoperatively for a long acting
agent such as chlorpropamide.
 A combination of glucose and insulin is the most satisfactory method
of overcoming the deleterious metabolic consequences of starvation
and surgical stress in the diabetic patient. Generally, there is no need
for insulin infusion in diabetics who are diet-controlled regardless of
type of surgery, or in diabetics who are on oral agents only and are
undergoing minor surgeries.

40.  Patients on steroids who present for surgery may be at increased risk of
complications because of
 The adrenal suppression
 The disease or condition which required them to take steroids
 Long-term and other side-effects of steroid therapy
 patient.info/doctor/precautions-for-patients-on-steroids-undergoing-surgery

41.  Establish how much steroid has been taken
and for how long.
 10 mg/day or more of prednisolone (or
equivalent) is generally taken as the
threshold dose for 'steroid cover'.

42.  The risk of adrenal suppression
 In normal healthy patients there is a prompt secretion of cortisol with the
onset of surgery and secretion remains elevated for several days after
surgery. Glucocorticoids are not stored and must be synthesised when
required - for example, during and after surgery. This response depends on
the hypothalamopituitary axis which may be suppressed or unresponsive
to stress when steroids have been taken. Failure of cortisol secretion may
result in the circulatory collapse and hypotension characteristic of an
hypoadrenal or 'Addisonian' crisis.

43.  Postoperative considerations

44.  Preoperative assessment
 This should focus on the history of steroid usage, routine examination
(including blood pressure) and basic investigations including FBC, U&Es,
blood glucose and LFTs.
 Investigation for adrenal suppression is rarely done. It is possible to assess
this with:
1. Serum and urinary cortisol.
2. Short synacthen test (SST) - more popular but interpret with care. [5]
3. Insulin tolerance test.
4. Corticotropin-releasing hormone (CRH) measurement.

45.  Patients on corticosteroids at a dose of 10 mg or more of prednisolone
 Patients who have received corticosteroids 10 mg daily within the three months
preceding surgery.
 Patients on high-dose inhaled corticosteroids
 Minor surgery - 25 mg hydrocortisone at induction
 Moderate surgery
 Major surgery

47.  Major concern is when to perform surgery. Ie
without risk of hemorrhage or
thromboembolism

48.  1. Most patients can undergo dental extractions, arthrocentesis,
biopsies, ophthalmic operations and diagnostic endoscopy without
alteration of their regimen.
 For other invasive and surgical procedures, oral anticoagulation
needs to be withheld and the decision whether to pursue an
aggressive strategy of perioperative administration of intravenous
(IV) heparin or subcutaneous (SC) low-molecular-weight heparin
(LMWH) should be individualized

49.  Management recommendations:
 1. If INR pre-op is 2-3, stop oral anticoagulant 4 days prior to
surgery (or longer if INR > 3.0).
 2. Measure INR one day prior to surgery: if it is ≥ 1.7, give 1 mg
vitamin K SC.
 3. If on the day of surgery the INR is 1.3-1.7, administer 1 unit of
fresh frozen plasma and administer 2 units if the INR is 1.7-2.0.
 4. The following approaches can be used: administer full-dose
anticoagulation with IV unfractionated heparin (UFH); administer
full-dose anticoagulation with LMWH; or administer prophylactic
doses of UFH or LMWH.

50.  2. Invasive surgery is generally safe (from major
hemorrhagic complication) when the INR ∼1.5.
 3. It takes approximately 4 days for the INR to reach 1.5
once oral anticoagulant is stopped preoperatively.
 4. It takes approximately 3 days for the INR to reach 2.0
once oral anticoagulant is restarted postoperatively.
 5. If oral anticoagulant is held 4 days pre-op and started
immediately post-op, the patient is, in the mean time,
without anticoagulation for 2 days

52.  The ultimate goals of preoperative medical assessment are to reduce the
patient’s surgical and anesthetic perioperative morbidity or mortality, and to
return him to desirable functioning as quickly as possible. It is imperative to
realize that “perioperative” risk is multifactorial and a function of the
preoperative medical condition of the patient, the invasiveness of the surgical
procedure and the type of anesthetic administered
 Laboratory investigations should be ordered only when indicated by the
patient’s medical status, drug therapy, or the nature of the proposed procedure
and not on a routine basis
 Proper consultations with appropriate medical services should be obtained to
improve the patient’s health. These consultations should ideally not be done in
a “last second” fashion

53. I. Ronald d miller. Anesthesia. Fifth edition
II. Wylie and churchill-davidson’s Apractice of anesthesia
III. HIPPOKRATIA 2007, 11, 1: 13-21
IV. How to read an electrocardiogram (ECG). Part One: Basic principles of the ECG. The
normal ECG. SSMJ Vol 3 Issue 2 May 2010
V. Precautions for Patients on Steroids Undergoing Surgery
VI. How to Read a Chest X-Ray – A Step by Step Approach . SSMJ Vol 1 Issue 2.
VII. Clinical Guideline for the Perioperative Steroid Replacemen
VIII. Preoperative evaluation of the patient with pulmonary disease. Rev Bras Anestesiol.
2014;64(1):22---34
IX. Pulmonary Function Tests.Harpreet Ranu, Michael Wilde, Brendan Madden. Ulster Med J
2011;80(2):84-90