PRE-OPERATIVE

ASSESMENT OF PATIENTS

N I K H I L PA N J I YA R ( I N T E R N )
1 S T B AT C H
BMC

MODERATOR : DR.ROSHAN PRADHAN.

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 Contents
•Objectives

•Introduction

•Goals

•Steps of preoperative visit

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 Objectives
•Evaluate the patient’s medical condition

•Optimise the patient’s medical condition

•Determine and minimize risk factors for anesthesia

•Plan anesthetic technique & perioperative care

•Facilitate conduct of anesthesia

•Inform and educate the patient & consent

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PREOPERATIVE ASSESMENT
INTRODUCTION

•Process of clinical assessment

•Preceding the delivery of anesthesia for surgery and for non surgical
procedures

•Patient’s interview, medical records, physical examination and findings

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 GOALS

• To ensure that the patient is in the best(optimal) condition.

• Unstable symptoms should be postponed for optimization prior to elective

• Focused review of all major organ system should be done prior to elective
surgery.

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STEPS OF PREOPERATIVE
VISIT

1. Problem identification

2. Risk assessment

3. Preoperative preparation

4. Plan of anesthetic technique.

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 PROBLEM
IDENTIFICATION
•Case history

•Physical examination

•Laboratory investigations

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 Case History

• Demographic details
• Presenting complaint
• History of presenting complaint
• Past medical history
• Previous anesthetic history
• Drug history
• Systemic enquiry

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 Physical examination

•General and local examination

•Evaluation of : upper airway special examination : airway assessment

respiratory system peripheral access

cardiovascular system spine examination

vitals sign

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 Airway

•Difficult airway : Conventionally trained anesthesiologist

•Evaluation is the first step in management of difficult

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 AIRWAY CLASSIFICATION SYSTEM

MALLAMPATI SCORE

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DIRECT LARYNGOSCOPIC VIEW
COOK MODIFICATION

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 Airway evaluation
• Mentothyroid distance : normal 6 cm.

• Mentosternal distance : normal 15 cm

• Mentohyoid distance : normal 3 FB

• Neck movement

• Nasal cavity

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 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 / parasthesias

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 Difficult intubation
• Interincisor distance less than 3 cm.
• Limitation of neck movement
• Micrognathia
• Macroglossia
• Thyromental distance less than 6 cm
• Protusion of teeth
• Short neck
• Morbid obesity

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 Patient assessment

•ASA physical status

•Cardiac risk :

1. Goldman’s multifactorial cardiac risk assessment

2. Detsky’s multifactorial index

3. Revised cardiac index

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 Pulmonary Disease
•Pulmonary complications occurs more frequently than cardiac complications
(5-10% incidence )
•Perioperative complications includes:
1. Aspiration
2. Atelectasis
3. Pneumonia
4. Bronchospasm
5. Hypoxemia
6. Acute exacerbation of COPD
7. Respiratory Failure requiring Mechanical Ventilation

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 Pre-operative Investigations
• General:
1. Complete Blood Count
2. Clotting screen
3. Liver function
4. ECG
5. Echocardiogram
6. Chest x-ray
7. Blood sugar level
8. Electrolytes, Blood Urea Nitrogen/ Creatinine

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 RISK ASSESSMENT
Components for evaluating perioperative risk

1. Patient medical condition preoperatively

2. Type or extent of surgical procedure

3. Risk from anesthesia

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 Preoperative Preparation
ANESTHETIC INDICATION
•Anxiolysis, sedation and amnesia: Benzodiazepam
•Analgesia: narcotics
•Drying of airway secretions e.g. atropine, glycopyrrolate
•Reduction of anesthetic requirements
•Facilitation of smooth induction
•Patients at risk for GE reflux : ranitidine,metoclopramide , sodium
citrate

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SURGICAL INDICATION
•Antibiotic prophylaxis for infective endocarditis.
•Prophylaxis against DVT for high risk patients : low-dose heparin or
aspirin, intermittent calf compression or warfarin

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CO-EXISTING DISEASE INDICATION
•Some medications should be continued on the day of surgery
•Others are stopped
•Steroids within the last six months may require supplemental steroids

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 Medication to be continued on the day of
surgery.
1. Antihypertensives except ACE Is and ARBs

2. Cardiac medications e.g B-blockers, digoxin

3. Antidepressants, anxiolytics

4. Thyroid medications

5. Birth control pills, eye drops, heartburn or reflux medications,

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 Medications to be discontinued
•Topical medications e.g creams and ointments

•Oral hypoglycemic agents (metformin) 3 days before and switch to

• Diuretics on the day of surgery

• Sildenafil or similar drugs – discontinue 24 hrs prior to surgery

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•NSAIDS – discontinue 48 hrs before surgery

•Warfarin ( Coumadin) discontinue 4 days before surgery

• lithium : 48-72 hrs prior to surgery.

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•Antiplatelet agents like clopidogrel and conventional
dose of aspirin should be stopped 7 days before
surgery

•Low dose of aspirin can be continued till the date of

•Clopidogrel can be continued in cataract surgery

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 NPO guidelines

Substance Maximum Hours of Fasting

Solid 8

Formula 6

Cow milk 6

Citrus juice 6

Breast milk 4

Clear liquid 2

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 Antibiotic Prophylaxis
•Cephalosporins are the most popular antibiotics because they cover
skin microbes,

•For intestinal surgery , anaerobic and Gram negative coverage is

•when tourniquet is used, the antibiotics should be administered prior to

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 Psychological Preparation
Preoperative visit and interview with the patient and family members,
• The anesthesiologist should explain anticipated events and the
proposed anesthetic management in an effort to reduce anxiety and
diminish apprehension.

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 PLAN OF ANESTHESIA
TECHNIQUE
• Local

• Regional anesthesia

• General anesthesia

• Combination.

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 REFERENCES
•Marino’s ICU book – 4th edition

•Short text book of anesthesia by Ajay yadav- 6th edition

•Zambouri A. Preoperative evaluation and preparation for anesthesia and

•Google for images

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 Thank You 

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