This document discusses the importance of preanesthetic evaluation by an anesthesiologist. It aims to ensure patients can safely tolerate anesthesia and mitigate perioperative risks. Key components include documenting medical history, performing examinations, optimizing conditions, ordering tests selectively, and discussing care. History taking and physical exams detect most issues. Tests are only needed based on history, procedure, and anticipated blood loss. The evaluation helps determine a patient's fitness and perioperative risk level. Medication management and fasting guidelines are also reviewed.

1. DR.CHARULATHA.R
Preanaesthetic evaluation

2.  anaesthesiologist = perioperative physician
 Use our unique knowledge and experience to
manage medical complexities related to
surgery
 3 % of perioperative adverse events were
related to inadequate preoperative
assessment

3. goals
 1.patients can safely tolerate anaesthesia for
planned surgical procedure
 2.to mitigate risks associated with overall
perioperative period

4. How do we achieve it?
 Document comorbid illness
 Perform focussed clinical examination
 Optimize preexisting medical conditions
 Make selective referrals to specialists
 Order preoperative investigations
 Initiate interventions to reduce perioperative
risk
 Discuss aspects of perioperative care

5. Anaesthesiologist lead PAC
 More selective ordering of laboratory tests
 Reduced healthcare costs
 Reduced patient anxiety
 Improved acceptance of regional anaesthesia
 Fewer case cancellations on day of surgery
 Shorter duration of hospitalization
 Lower hospital costs

6. Medical consultation?
 Management of unstable medical conditions
before elective surgery
 Preop optimization of poorly controlled
medical diseases
 Clinically relevant preop diagnostic workup
 Uncommon medical disorder

7. Detecting disease
 All that is required is clinical examination
 History taking -56%
 Physical examination -73%
 ECGs and chest Xrays -3%
 Stress tests -6 %
 Respiratory ,urinary,neurolgic-history

8. Components of medical
history
 Ask the right question
 Indication for surgery and planned procedure
 Development of surgical condition and prior
related therapies
 Current and past medical problems,pervious
surgical procedures,types of anaesthesia ,any
anaesthesia related complications
 allergies

9. Personal history
 Tobacco, alcohol ,illicit drug use
 Quantitative documentation of tobacco
exposure
 Pseudocholinesterase deficiency/ Malignant
hyperthermia
 Snoring and excessive daytime sleepiness
 Last menstrual period
 GE reflux
 Excessive bleeding problems

10. Comorbid conditions
 Severity,stability,exarcerbations
 Prior treatments,planned interventions
 Degree of control
 Activity limiting nature of problems
 Medications and schedules
 Recent corticosteroid use

11. METs
 Assessment of functional capacity
 Metabolic equivalents of the task
 Measure of volume consumed during an
activity
 Poor exercise capacity may be the cause or
result of cardiopulmonary disease
 Inability to perform average levels of exercise
increases risk of perioperative complications

12. Physical examination
 Vital signs
 BMI
 Airway examiation
 Evaluation of heart,lungs ,spine
 Direct observation of exercise tolerance
 Basic neurologic examination
 Carotid bruit

13. Components of airway
examination
 Length of upper incisors
 Visibility of uvula
 Compliance of mandibular space
 Thyromental distance
 Length and circumference of neck
 Range of motion of head and neck
 Relationship of upper incisors to lower
incisors

14. Cardiovascular diseaase
 Hypertension
 Ischemic heart disease
 Coronary stents
 Heart failure
 Murmurs and valvular abnormalities
 Rhythm disturbances in preoperative ECG
 Peripheral arterial disease

15. hypertension
 Identify cause,other cardiovascular risk
factors,end organ damage
 BP measurement in both arms
 Investigations?
 Elective surgery delayed when systolic> 200 mm
Hg or diastolic >115 mm Hg
 BP less than 180/110 mm Hg
 Future appropriate postop management of
inadequately treated hypertension
 ACE inhibitors and ARBs

16. Ischemic heart disease
 Step 1-emergency surgery
 Step2- active cardiac conditions
 Step 3 –low risk surgery
 Step 4- functional capacity
 Step 5- clinical predictors

17. Revised cardiac risk index
 High risk surgery
 Ischemic heart disease
 History of congestive heart failure
 History of cerebrovascular disease
 Diabetes mellitus requiring insulin
 Creatinine >2.0 mg/dL

18.  Preoperative anaemia is associated with
increased perioperative cardiac events
 Increasing blood transfusion rates does not
decrease perioperative cardiac risk
 Anaemia decreases effects of beta blocker
therapy
 Increased harm when the patient is bleeding

19. ECG
Patients with symptoms /suggestive of
ischemia
For intermediate to high risk surgical
procedures
Not needed in superficial procedures or simply
because of advanced age
Q waves,RBBB,LBBB - important

20.  Statins and beta blockers continued
 Beta blockers should be started several days
before the procedure
 Caution in patients with cerebrovascular
disease
 Aspirin is continued where the risk of cardiac
events exceeds risk of major bleeding

21. Neurologic disease
 Cerebrovascular disease- recent stroke orTIA
is a very strong predictor of subsequent
perioperative stroke
 Asymtomatic bruit- carotid doppler studies
 Seizure disorder- CBC and electrolytes
 Parkinson disease
 Neuromuscular junction disorders

22. Preoperative tests
 Should be based on
 1.patient ‘s medical history
 2.proposed surgical procedure
 3.potential for intraoperative blood loss
 Selective testing enhances the standing of
speciality in perioperative medicine

23. CBC
 History of increased bleeding
 Hematologic disorders
 Renal disease
 Recent chemo or radiation
 Corticosteroid or anticoagulant therapy
 Poor nutritional status
 Trauma
 Anticipated high blood loss

24. Renal function testing
 Diabetes and hypertension
 Cardiac disease
 Fluid overload
 Renal transplantation
 Recent chemotherapy
 Potential dehydration
 Hematuria,oliguria,anuria

25. Liver function tests
 History of hepatitis
 Jaundice
 Cirrhosis
 Hepatotoxic drug exposure
 Bleeding disorders
 Tumor involvement of liver

26. Coagulation testing
 Known bleeding disorders
 Previous excessive intraoperative bleeding
 Hepatic disease
 Poor nutritional status
 Anticoagulants
 Routine testing not needed unless
coagulapathy is suspected or known

27. Chest radiograph
 No evidence indicates that routine
preoperative chest radiographs provide
prognostically important information for
assessing patients perioperative risk
 Rales or rhonchi
 Advanced copd/suspected pulmonary edema
 Pulmonary/mediastinal masses
 Aortic aneursym

28. Preoperative risk assessment
 Improves patient’s understanding
 Helps clinical decision making
 Improves perioperative outcomes
 ASA PS classification
 John Hopkins Surgery Risk Classification
System

29. ASA PS
 1- a normal healthy patient
 2- a patient with mild systemic disease
 3- a patient with severe systemic disease
 4- a patient with severe systemic disease that
is a constant threat to life
 5- a moribund patient who is not expected to
survive without operation
 6-declared brain dead donor

30. Role of specialized testing
Resting echocardiography-
Valves
Pulmonary hypertension
Fixed wall motion abnormalities
Ventricular function
Dyspnea of unknown origin
Recent altered clinical status in a known heart
failure patient

31. CPET
 Non invasive global assessment of exercise
capacity
 Involves a patient exercising on a treadmill or
bicycle for 8 to 12 minutes
 Continuous measurement of respiratory gas
exchange
 Poor exercise capacity associated with
increased postoperative mortality/morbidity

32. PFT
 Help differentiate between pulmonary and
cardiac cause of dyspnea
 Assess perioperative risk in lung resection
surgery
 Prognostic value limited

33. Medication management -stop
 Clopidogrel-7 days before surgery
 Ticlopidine -14 days
 Insulin- short acting –discontinue
 Type 1 diabetes- 1/3 rd of long acting morning
dose
 Type 2- upto ½ of long acting or combination
 OHAs
 Diuretics –except thiazides

34. stop
 Warfarin- 4 days before surgery except for
patients having cataract surgery withot
bulbar block
 NSAIDS – 48 hrs before surgery
 Sildenafil-24 hrs before surgery
 ACEI and ARBs

35. continue
 Antihypertensive medications
 Cardiac drugs
 Antidepressants,anxiolytics
 Thyroid
 Anticonvulsant
 Asthma
 Steroids
 Statins
 MAO inhibitors

36. Preoperative fasting status
 Clear fluids -2 hrs
 Breast milk -4 hrs
 Formula milk -6 hrs
 Light meal -6 hrs
 Fried fatty meal -8 hrs

37. Postoperative pain
management
 Visual analog score
 McGill pain questionnaire
 Uses
 1.patient’s concern
 2.preoperative instructions
 3.improves patient acceptance of regional
anaesthesia
 4.patients with chronic pain syndromes