Anesthesia preanaesth check up important considerations

1. Dr Radhika Raj M R
Guide: Dr Nidhi

2. Pre Anaesthetic Evaluation
• Defnition
The process of clinical assessment that precedes the delivery of
anesthesia care for surgery and for non-surgical procedures.
• Preoperative evaluation is an integral component of the
anesthesiologists’ role as perioperative physicians who are involved in
integrated medical care before, during, and after surgery

3. Goals and Benefits of PAC
• To ensure that the patient can safely tolerate anesthesia for the planned surgery.
• Mitigate perioperative risks
• Better document comorbid illness
• Reduce the patient’s (and family’s) anxiety through education
• Optimize preexisting medical conditions
• Order specialized investigations
• Initiate interventions intended to decrease risk
• To discuss aspects of perioperative care (e.g.anticipated risks, fasting guidelines),
• To arrange appropriate levels of postoperative care
• To predict the difficulty during intubation
• To obtain informed consent

4. Clinical examination
1. Medical History
2. Physical examination
Medical history
 Planned surgery and its indication
 Current known medical problems and past medical issues
 Diseases or symptoms their associated severity, stability, associated
activity limitations, exacerbations (current or recent), prior treatments, and planned
interventions
 Previous surgeries, anesthesia types, and anesthesia-related complications
 Prescription and over-the-counter medications should be documented, along with
their dosages and schedules

5.  any allergies to medications and other substances
Addictions-tobacco,alcohol,drugs consumption
smoking history
Pack year :No. cigarettes smoked per day x years smoked /20
20 pack years is considered as a significant factor for developing COPD
Family history: personal or family history of pseudocholinesterase deficiency and
malignant hyperthermia (including a suggestive history such as hyperthermia or
rigidity during anesthesia) must be clearly documented to facilitate appropriate planning
before the day of surgery. Information from previous anesthetic records may clarify an
uncertain history
Menstrual history: LMP

6. ASSESSMENT OF FUNCTIONAL CAPACITY
• Assessment of the patient’s cardiopulmonary fitness or functional capacity is an
integral component of the preoperative clinical examination
• Functional capacity is typically quantified in using the metabolic equivalent of task
(MET)
• One metabolic equivalent of task (MET) is the amount of oxygen consumed while
sitting at rest, and is equivalent to an oxygen consumption of 3.5 mL/min/kg body
weight.
• Value :- 1 – 12
(Light – Moderate – Vigorous)

8. Dukes activity status index
• 1-4 METS ( eating,dressing ,walking around the house,dish washing)
• 5-9METS ( Climb a flight of stairs ,walk one or 2 blocks on level ground,run a short
distance,moderate activites like golf,dancing )
• >10 METS ( sternous sports (swimming ,bicycle,tennis),heavy professional
domestic work

9. PHYSICAL EXAMINATION
GPE – Weight,Height, BMI
Higher mental function
Built
Nutritional Status
Nails :Cyanosis, Clubbing
Conjunctiva
Sclera ( Jaundice)
Back & Spine
Edema
Gait
Vital Signs – BP
Pulse
RR
Temperature

10. Airway examination
Pt is asked about:-
• Artificial Dentures
If yes it must be either removed / protected during the course of anesthesia
• Teeth ( Loose, Cracked, Chipped, Capped)
• Mouth opening
• Jaw Joint ( if it clicks, pops or hurts)
Maybe TM joint syndrome accompanied by chronic pain / repeated dislocation of
jaw.
• Snoring (Predictor of difficult intubation)
• Day time sleep (Somnolence) ( Sleep Apnea)

12. MALLAMPATI CLASSIFICATION
• Class I: soft palate, tonsillar fauces,
tonsillar pillars, and tip of uvula
visualized
• Class II: soft palate, tonsillar fauces,
and uvula visualized
• Class III: soft palate and base of uvula
visualized
• Class IV: only hard palate visualized
Class III and IV→ Difficult to
Intubate

13. DIFFICULT MASK VENTILATION
Predictors
• Age more than 55 years,
• BMI more than 26 kg/m2
• Absence of teeth
• Presence of a beard
• History of snoring
Others
• increased neck circumference
• face and neck deformities (i.e., prior surgery, prior radiation, prior trauma, congenital abnormalities)
• Rheumatoid arthritis-cervical spine is often affected-atlanto axial instability
• Trisomy 21 (Down syndrome)-microstomia,macroglossia,atlanto axial instability and sublaxation
• scleroderma -autoimmune condition causing fibrosis of skin-contractures may be
seen,microstomia,mandibular bone resorption -difficult intubation and difficul vascular assess
• cervical spine disease, or previous cervical spine surgery

15. UPPER LIP BITE TEST
ULBT is considered to be highly accurate in
predicting difficult mask ventilation as it
assesses both buck teeth & mandibular
subluxation simultaneously.
* It is performed according to following criteria:
Class 1 lower incisors can bite the upper lip
above the
vermilion line.
Class 2  lower incisors can bite the upper lip
below the
vermilion line.
Class 3 lower incisors cannot bite the upper
lip.

16. RULE OF 123….
1. Temporomandibular jt: ability to insuniate 1- finger in front of
tragus with mouth open.
2. Mouth opening inter-incisor gap should be at least 2-finger
breadth.
3. Thyromental distance should be at least 3-finger breadth.
 Hyomental distance 2 finger breadth of adult

17. • PATIL TEST –
Measures distance between thyroid notch &
mental symphysis (thyromental gap)
> 6.5 cm – Normal
6.0-6.5 cm – Intubation & Laryngoscopy
possible but difficult
< 6.0 cm –Very difficult Laryngoscopy and
intubation
• HYOMENTAL DISTANCE –
Grade 1 : > 6 cm
Grade 2 : 4-6 cm
Grade 3 : < 4 cm ( very difficult
laryngoscopy )

18. PRAYER SIGN:
• To evaluate the prayer sign, patients
are asked to approximate the palmar
surfaces of their hands. If the palmar
surfaces of phalangeal joints touch
completely, the prayer sign is negative.
If the palmar surfaces of the phalangeal
joints could not be approximated
despite maximal effort, the prayer sign
is positive.

19. PALM PRINT TEST:
The palm and fingers of the dominant hand of the
patient is painted with black writing ink using a
brush. The patient then presses the hand firmly
against a white sheet of paper on a hard
surface. Scoring is done as:
* Grade 0 - All phalangeal areas are as visible.
* Grade 1 - Deficiency in the inter-phalangeal
areas of 4th and/or 5th digit.
* Grade2 - Deficiency in the inter-phalangeal
areas of 2nd to 5th digit.
* Grade 3 - Only the tips of digits seen.

20. Respiratory System
• History of cough
• H/o of TB, Asthma, Pneumonia
• H/o of Smoking
Inspection
• cyanosis
• clubbing,
• accessory muscle use
• respiratory effort
Auscultation
• wheezing
• decreased breath sounds
• abnormal breath sounds

21. Risk Factors for Postoperative Pulmonary Complications

22. Cardiovascular system
• We need to check that the pt is having any the
following conditions or not : CHF
HTN
IHD
Cardiomyopathy
Valvular / Subvalvular ds
Arrhythmias
Atherosclerosis
• To assess CVS: the pt is asked about
-- Shortness of breath(at rest,sleep)
-- chest pain, chest tightness
-- Pedal edema
-- Previous Heart / Lung surgery
-- medication

23. Revised Cardiac Risk Index
23
High-risk surgery (intraperitoneal, intrathoracic, or 1
suprainguinal vascular procedures)
Ischemic heart disease (by any diagnostic criteria) 1
History of congestive heart failure 1
History of cerebrovascular disease 1
Diabetes mellitus requiring insulin 1
Creatinine >2.0 mg/dL 1
Components Points
Assigned
Revised Cardiac Risk Index Score Risk of Major CardiacEvents
0 0.4%
1 1.0%
2 2.4%
≥3 5.4%

24. Hypertension
• Blood pressure > 140/90 mmHg
• Measurement should be >2 times on different occasion
• Should be taken in both arms
• The goals of preoperative evaluation are to identify any secondary causes of
hypertension, presence of other cardiovascular risk factors (e.g., smoking,
diabetes mellitus), and evidence of end-organ damage.
• The physical examination should focus on vital signs, thyroid gland, peripheral
pulses, and cardiovascular system (including bruits and signs of intravascular
volume overload).
• Cancellation/ postpone case if BP > 180/110 mmHg
• Stop ACE inhibitor and ARBs and continue beta blocker and clonidine

25. NYHA CLASSIFICATION
• NYHA class I: no limitation of physical activity; ordinary activity not a
cause of fatigue, palpitations, or syncope
• NYHA class II: slight limitation of physical activity; ordinary activity
resulting in fatigue, palpitations, or syncope
• NYHA class III: marked limitation of physical activity; less than ordinary
activity resulting in fatigue, palpita_x0002_tions, or syncope; comfort at
rest
• NYHA class IV: inability to do any physical activity without discomfort;
symptoms at rest

26. Renal system
• The preoperative evaluation of patients with CKD should emphasize the cardiovascular
system, cerebrovascular system, intravascular volume status, and electrolyte status.
• The early stages of CKD typically cause no symptoms.
• The anesthesiologist should inquire about the cardiovascular systems (i.e., chest pain,
orthopnea, paroxysmal nocturnal dyspnea), urine output, associated comorbidities,
medications, dialysis schedules, and any hemodialysis catheter problems (e.g., infection,
thrombosis).

27. Hepatic system
• Most of the patients with liver disease will be asymptomatic
• Some may complain Fatigue, weight loss, dark urine, pale stools, pruritus, right
upper quadrant pain, bloating, and jaundice
• Physical Examination : jaundice, bruising, ascites, pleural effusions, peripheral
edema, hepatomegaly, splenomegaly, and altered mental status
• Past history of liver disease should be asked

28. ENDOCRINE SYSTEM
Endocrine disturbances & end organ effects of -
DM
Thyroid/Parathyroid
Pituitary
Adrenals
Can increase perioperative risk substantially.
* Pt is asked about
--waking up at night freq to urinate (DM)
--increased thirst (DM)
--increased perspiration than others (Pheochromocytoma)
--Headache (Pheochromocytoma)
--Feeling more cold/warm (hypo/hyperthyroid)
--Muscle cramps/spasm in legs >3 times a year (Thyroid)

29. • Diabetes
• Blood Sugar
– Normal :-
Fasting :- 70-100 mg %
PP :- less than 126 mg %
– Diagnostic Criteria :-
Fasting :- > 125 mg % or
Glucose tolerance test > 200 mg % (2 hr.)
Random :- 200 mg % or more with symptoms ( polyurea, polydypsia, unexplained
wt.loss)
• usual glycemic control, history of hypoglycemic episodes, current therapy, and the
severity of any end-organ complications should be documented
• physical examination
– evaluation of pulses
– skin breakdown
– joint (especially cervical spine) mobility

30. NEUROLOGICAL SYSTEM
Pt is asked about
-- h/o seizure / convulsion / stroke/fall/
head injury/head surgery
-- pin & needle sensation in arms & legs
-- Migraine

31. MUSCULOSKELETAL SYSTEM
Pt is asked about
-- h/o arthritis
-- low back pain
-- taking pain pills/pain shots in last 6 months
Examination of Back & spine:
-- Done to evaluate any congenital deformity/ kyphoscoliosis etc.
-- to assess whether spines are fused or not.

32. HEMATOLOGICAL SYSTEM
Pt is asked about
-- problem with blood clotting if any after minor cuts / bruise
-- H/O spontaneous bleeding
-- H/O blood transfusion

33. INVESTIGATION
• COMPLETE BLOOD COUNT, HEMOGLOBIN, AND HEMATOCRIT
• Typical clinical indications include
– history of increased bleeding
– hematologic disorders
– CKD
– chronic liver disease,
– recent chemotherapy or radiation treatment
– corticosteroid therapy
– anticoagulant therapy
– poor nutritional status

34. Renal function test
• clinical indications include
– diabetes mellitus
– hypertension
– cardiac disease
– potential dehydration (e.g., vomiting, diarrhea)
– anorexia
– bulimia
– fluid overload states (e.g., heart rate, ascites)
– known renal disease, liver disease
– relevant recent chemotherapy (e.g., cisplatin, carboplatin)
– renal transplantation

35. LIVER FUNCTION TESTING
• clinical indications include
– a history of hepatitis (viral, alcohol, drug-induced, autoimmune)
– jaundice
– cirrhosis
– portal hypertension
– biliary disease
– gallbladder disease
– hepatotoxic drug exposure
– tumor involvement of the liver
– bleeding disorders

36. COAGULATION TESTING
• indications for testing
– include a known bleeding disorder
– hepatic disease
– anticoagulant use.

37. URINALYSIS
• clinical indications include
– suspected urinary tract infection
– unexplained fever or chills

38. PREGNANCY TEST
• Practice Advisory for Preanesthesia Evaluation” suggests offering pregnancy
testing to female patients of childbearing age when the result would alter the
patient’s management.

39. ELECTROCARDIOGRAM
• clinical indications include
– a history of IHD
– hypertension
– diabetes mellitus
– heart failure
– chest pain
– palpitations
– abnormal valvular murmurs
– peripheral edema
– syncope
– dizziness
– dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea,
– CVD

40. Chest XRAY
• clinical indications include
– advanced COPD
– bullous lung disease
– suspected pulmonary edema
– suspected pneumonia
– suspected mediastinal masses
– suspicious findings on physical examination (e.g., rales, tracheal deviation)

41. Special Consideration For Thyroid
• indirect laryngoscopy
• ENT check up for vocal cords
• Recent TFT
• Possibility of difficult intubation
• Pre op tracheostomy consent for possible tracheomalacia

42. American Society of Anesthesiologists Physical Status
Classification

44. Recommenedation of steroids in perioperative
patients

45. NBM for the surgery

46. Conclusion
• Pre anaesthetic evaluation is the clinical foundation for guiding perioperative
patient management and it has the potential to reduce perioperative morbidity and
enhance patient outcome.
• The fundamental purpose of preoperative evaluation is to obtain pertinent
information regard_x0002_ing the patient’s medical history, formulate an
assessment of the patient’s perioperative risk, and develop a plan for any requisite
clinical optimization.
• The anesthesiologist is the perioperative medical specialist and thus is uniquely
positioned to evaluate the risks associated with anesthesia or surgery, discuss these
risks with the patient, and manage them perioperatively in collaboration with the
surgical team, referring physician, and other medical specialists

47. Referances
• Millers 9th edition
• Airway management by Rahid Khan