Preoperative Assesment & Premedication

Preoperative Assesment & Premedication

PREOPERATIVE ASSESSMENT & PREMEDICATION OUTLINE Goals of assessment . Clinical picture of the patient ( H & P/E ). Evaluating cardiac and respiratory systems.

Airway examination. ASA classification. Pre operative testing. Fasting status. Premedication. Pre-operative Evaluation

General Specific Pre-operative This applied both in evaluation & investigations

General This include the following: 1-General condition of the patient.

2-Psychological condition. ( Specially in major operations). Specific This include the following:

1-Related to anaesthesia. 2-Related to the surgery. Assessment Air way.

Class and grade of surgery. General condition of the patient.

Significant History (Suggests increased risk of difficult intubation) Stridor Significant Snoring Sleep Apnea Advanced Rheumatoid Arthritis Dysmorphic Facial Features Upper Respiratory Infections

Obesity Clinical Picture Full medical history and physical examination Points of specific relevance to anaesthesia: - General health of patient and functional capacity - Surgical procedure - Concurrent medical conditions and medication

History of reactions and allergies to anesthesia - THE AIRWAY - Fasting Status Airway Examination Normal Opens mouth normally (Adults: greater than 2 finger widths or 3 cm)

Able to visualize at least part of the uvula and tonsillar pillars with mouth wide open & tongue out (patient sitting) Normal chin length (Adults: length of chin is greater than 2 finger widths or 3 cm) Normal neck flexion and extension without pain / paresthesias Airway Examination

Abnormal Small or recessed chin Inability to open mouth normally Inability to visualize at least part of uvula or tonsils with mouth open & tongue out High arched palate

Tonsillar hypertrophy Neck has limited range of motion Low set ears Signficant obesity of the face/neck Mallampati test

American Society of Anesthesiologists Patient Classification 1 =A normal healthy patient 2 =A patient with a mild systemic disease 3 = A patient with a severe systemic disease that limits activity, but is not incapacitating 4 =A patient with an incapacitating systemic disease that is a constant threat to life 5 =A patient not expected to survive 24 hours with

or without operation ASA - 1 ASA 1 A normal, healthy patient. The pathological process for which surgery is to be performed is localized and does not entail a systemic disease. Example: An otherwise healthy patient

scheduled for a cosmetic procedure. ASA - 2 ASA 2 A patient with systemic disease, caused either by the condition to be treated or other pathophysiological process, but which does not result in limitation of activity. Example: a patient with asthma, diabetes, or

hypertension that is well controlled with medical therapy, and has no systemic sequelae ASA - 3 ASA 3 A patient with moderate or severe systemic disease caused either by the condition to be treated surgically or other

pathophysiological processes, which does limit activity. Example: a patient with uncontrolled asthma that limits activity, or diabetes that has systemic sequelae such as retinopathy ASA - 4 ASA 4 A patient with severe systemic disease that

is a constant potential threat to life. Example: a patient with heart failure, or a patient with renal failure requiring dialysis. ASA - 5 ASA 5 A patient who is at substantial risk of death within 24 hours, and is submitted to the procedure in desperation.

Example: a patient with fixed and dilated pupils status post a head injury. Emergency Status (E) This is added to the ASA designation only if the patient is undergoing an emergency procedure. Example: a healthy patient undergoing

sedation for reduction of a displaced fracture would be an ASA1 E. Pre-operative Investigations General: 1- FBP

all patients. 2- Clotting screen all patients and those on anticoagulants. 3- Liver function. 4- ECG

all patients > 40Ys. 5- Echocardiogram Abnormal ECG, ischemic heart. 6- Chest x-ray All patients >30Ys. 7- Blood sugar level. Full blood count all patients undergoing major (grade 3 or 4) surgery patients with severe (ASA 3) cardiac or

respiratory disease severe renal disease (creatinine > 200) patients with a history of anaemia patients who require a cross match or group patients with a bleeding disorder patients with chronic inflammatory conditions such as rheumatoid arthritis.

Urea and electrolytes all patients with known or suspected renal dysfunction all patients with cardiac disease (including hypertension on treatment) all patients on diuretic treatment patients with severe respiratory disease on steroid or theophylline therapy

all patients with diabetes all patients for major (grade 3 or 4) surgery ECG all patients aged 60 and over all patients with cardiovascular disease, including hypertension

all patients with severe (ASA 3) respiratory or renal disease aged 40 and over Echocardiography Predictors of increased perioperative risk are: Severe aortic or mitral stenosis

Severe left ventricular dysfunction Cardiomyopathy Pulmonary hypertension Chest x-ray (CXR) all patients for major vascular surgery suspected malignancy including lymph node biopsy all children; adults with

any respiratory signs or symptoms patients with cardiac or pulmonary disease for grade 4 (major+) surgery patients who have severe (ASA 3) cardiac or pulmonary disease anticipated ICU admission Coagulation screen

personal or family history of abnormal bleeding suspected liver dysfunction (cirrhosis, alcohol abuse, metastatic cancer) current anticoagulant therapy Cervical spine x-ray (flexion and

extension views) ideally all patients with rheumatoid arthritis whether or not they have neck symptoms cooperative patients with Downs Syndrome alternatively such patients could be considered to have an unstable cervical spine and treated accordingly

Other tests Glycosylated haemoglobin (HbA1c): recent result within past 3 months for all diabetic patients current random blood glucose in known or suspected diabetes g) Liver function tests: hepato-biliary or pancreatic disease known alcohol abuse

major gastrointestinal surgery Other tests Arterial blood gases : patients with severe (ASA 3 or 4) respiratory or renal disease for major surgery consider venous blood gases and oxygen saturation (pulse oximeter) as

an alternative to ABG sampling k) Lung function tests: patients with severe (ASA 3) respiratory disease undergoing major surgery patients having scoliosis surgery asthmatics need a peak flow recorded Other tests Thyroid function tests:

Results within past 3 months for patients about to undergo thyroid surgery or if thyroid replacement therapy has been recently changed Results from within the last year for patients stable on thyroid replacement therapy Pregnancy test if there is any doubt that a female patient may be pregnant (with her consent)

women must be made aware of the risks of surgery and anaesthesia to the fetus General Condition This will determine: 1- What sort of general investigations to be done.

2- The degree of risk. 3- Expected morbidity. Classification of Operations Clean Surgery.

Clean-Contaminated. Contaminated.

Dirty. Clean Operations In which no inflammation is encountered .

The respiratory, alimentary or genitourinary tracts are not entered. There is no break in aseptic operating theatre technique.

Clean-contaminated Operations In which the respiratory, alimentary or genitourinary tracts are entered.

but without significant spillage. Contaminated Operations Where acute inflammation (without pus) is encountered.

Or where there is visible contamination of the wound. Examples include gross spillage from a

hollow viscus during the operation Or compound/open injuries operated on within four hours. Dirty Operations In the presence of pus.

where there is a previously perforated hollow viscus, Or compound/open injuries more than four hours old. PROBABILITY OF WOUND INFECTION

Clean 0 Risk Index 1 1.0%

2.3% 2 5.4% Clean-contam. 2.1%

4.0% 9.5% Contaminated 3.4% 6.8%

13.2% Grades of Surgery

Grade I (Minor) Excision of a skin lesion or drainage of abscess. Grade II (Intermediate) Tonsillectomy, correction of nasal septum, arthroscopy.

Grade III (Major) Thyroidectomy, total abdominal hysterectomy. Grade IV (Major+) Radical neck dissection, joint replacement, lung operations Grades of surgery

This can help in estimating: 1- Expected time. 2- Morbidity & risk. 3- Need for blood transfusion. DVT is related directly to the duration of surgery.

Grade I (minor) Grade I (minor) Grade II surgery (intermediate) Grade III (Major) FASTING STATUS

6 hrs solids 4 hrs liquids 2 hrs clear fluid /water The Full Stomach Mechanisms Reflux Delayed gastric emptying

Raised abdominal pressure Pharyngeal and laryngeal incompetence The Full Stomach Clinical conditions GORD Opioids Autonomic

neuropathy: diabetes Pregnancy Intestinal obstruction Trauma

Head Injury Myopathies/ bulbar palsy Preoperative measures to reduce risk of aspiration Proton pump inhibitors H2 blockers

Metoclopramide Sodium citrate Nasogastric tube where applicable Summary of Fasting Recommendations to Reduce the Risk of Pulmonary Aspiration

Ingested Material Period Minimum Fasting (Hours) Clear liquids Breast milk Infant formula

Non-human milk Light meal 2 4 6 6 6

Risk factors for DVT

Age >40 years Obesity Varicose veins High oestrogen pill

Previous DVT or PE Malignancy Infection Heart failure / recent infarction Polycythaemia /thrombophilia Immobility ( bed rest over 4 days) Major trauma Duration of surgery.

Incidence of DVT and fatal pulmonary embolism Low risk = <0.01% Moderate risk = 0.5% High risk = 5%

High risk is 500 times the low risk. Pre-operative counselling Ensure that indication for operation is still valid. Identify any other medical condition. Discuss options with patient /

relatives. Consent. Prophylactic antibiotic Prophylactic against DVT. Pain control. Nutrition. Discussed with patient & his relatives.

Routine Preoperative care for the Adult Patient 1. Avoid taking aspirin or aspirin-containing products for 2 weeks prior to surgery unless approved by physician 2. Discontinue nonsteroidal anti-inflammatory

medications 48 to 72 hours before surgery 3. Bring a list or container of current medications 4. Bring an adult relative who can drive if they are having an outpatient procedure with sedation or general anesthesia Routine Preoperative care for the Adult Patient 5. Wear loose clothing that can easily be removed (eg, avoid clothing that pulls on and off over the head).

6. Instruct the patient to bathe/shower the evening before or morning of surgery. Men should be cleanly shaved. 7. Instruct the patient on oral intake restrictions and medication schedule as ordered: a. NPO after midnight (including water) b. NPO after clear liquid or light breakfast if permitted

On going to the operating room He/she will have to remove: 1. Dentures/partial plates 2. Glasses/contact lenses 3. Appliances/prosthesis

4. Makeup/nail polish 5. Hairpins/hairpiece Patient sketch 1 53 year old female for ligation of varicose veins She has a history of asthma and neglects her medication o/e anxious

RR 24/min widespread rhonchi PEF 65% Other systems unremarkable Patient sketch 2 64 yr old male with intestinal obstruction for a laparatomy

History of COPD previous heavy smoker Gets breathless walking uphill or fast on level ground Coughing purulent sputum FEV 75% 1 On combined therapy with beta 2 agonist and anticholinergic

Patient sketch 3 55yr old female for hysterectomy Diabetic on twice daily insulin BP 140/90 What investigations and management Patient sketch 4

22 kg child for removal of plaster cast Fasting from midnight In theatre at 10.00am What is her fluid deficit? Patient sketch 5 84 yr old female with a fractured neck of femur

Tripped in bathroom lives alone and lay there for 20 hours She is thin stature, lives on tea, toast and cake History of CCF On diuretics ? Considerations and management Patient sketch 6

40 yr old male for elective cholecystectomy Heavy smoker HR 80/min BP 200/115 Hb 14.0 gm/dl Urea 8 mmols/l Creatinine 140mmols/l Patient sketch 7

40 yr old male for cholecystectomy HR 80/min reg BP 150/95 Hb 12.8 gm/dl Urea 5.8 mmols/l Creatinine 115 mols/l Na 130mmols/l K 4.5mmols/l

Patient sketch 8 44 year old female for mastectomy and reconstruction 5 year history of angina, becoming more frequent and increasing in severity over past 6 months Both parents died from myocardial infarction Coronary angiogram 2yrs ago no vessel disease Ca antagonists,glyceryl trinitrate, isosorbide

dinitrate, verapamil, Risk Factors Investigations Management THANK YOU

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