PRE ANAESTHETIC

ASSESSMENT
Dr.Subbareddy
Anaesthesiology pg
 PREOPERATIVE ASSESSMENT

 Any patient scheduled for surgery should

be assessed by an Anaesthetist.
 This is called Pre operative assessment.
 Ideally it is performed by the person who
will administer the anaesthetic.
 For elective minor operations, admission
to hospital takes place one day before.
 This permits time for complete
examination.
 If the surgery is major or if the patient has
severe cardiac or pulmonary restrictions
more than one day may be required.
 The primary goal is to obtain information
required to plan anaesthetic management.
The overall objective is reduction of
Peri-operative morbidity & mortality.
 HOWTO CONDUCT
PRE-OPERATIVE EVALUATION
OR
PRE-ANAESTHETIC CHECKUP
(PAC) ?

1. History
2.Physical examination
3.Laboratory tests
 HISTORY:

1.General information regarding

Age, Sex, Weight, Occupation, Community
(whether patient belongs to Vaisya as
there is a Genetic predisposition to
Atypical Cholinesterase which can result in
prolonged suxamethonium apnoea.)
 HISTORY:
2. Any medical illness in past / present
(Epilepsy, Asthma, TB, Hypertension,
DM…..)
3. Previous Aneasthesia:
History related to previous surgical
procedures & anaesthesia given should be
obtained.
If the patient gives H/O difficult
intubation, Prolonged recovery, Reactions
to drugs or blood transfusions carefully
look into the discharge summary notes if
available.
HISTORY:
4. Drug intake & Allergy to any drug details
to be noted.
5. Personal habits: smoking, alcoholism,
addictions…
Smoking: to be stopped preferably
6 weeks before surgery.
Stopping smoking reduces airway
hyperactivity & thus decreases the
intraoperative & post operative pulmonary
complications. The level of COHb
decreases & more O2 is available to
tissues
 Alcoholic patients can have liver disease,
Cardiomyopathy, anaemia, gastritis,
polyneuropathy, nutritional deficiencies…..
 Drug addiction can lead to increased
requirement of narcotics & sedatives.
Modifications in Pre-existing
Medical Therapy :

1. Oral Hypoglycemics:

in minor surgery (<20min)—to be

continued omitting the morning dose,

in major surgeries – Switch over to plain

insulin atleast 48hrs before the surgery.
 insulin—
 Most of patients are either on intermediate
acting or mixed insulin.
 Adjustments in the doses of insulin are
done as per regime followed by particular
institute.
2. Oral Contraceptives:
estrogen containing pills—to be stopped
4weeks before surgery in elective cases.
In emergency stopping of pill is not possible
So give low dose heparin prophylactically in
Post operative period to prevent deep vein
thrombosis.
Pills containing only Progesterone need not
be stopped.
 3.oral anti coagulants
 To be stopped 4days prior and swith over to
heparin which is stopped 12-24 hrs prior to
surgery.in emergency warfarin effect
reversed with vit.k if possible wait for 4-6
hrs as vit.k takes 4-6 hrs to completely
reverse effects of warfarin.
 In life threating conditions effects of
warfarin reversed with fresh frozen plasma
 4.Heparin
 LMWH should be stopped 12-24 hrs prior
to surgery.
 Prophylactic dose stopped 12 hrs prior and
therapeutic dose stopped 24 hrs prior.
 Standard or unfractionated heparin has
short life so stopping 6-12hrs prior surgery
sufficient.
 .
 5.Thrombolytic or fibrinolytic therapy
 Pts can be consider for elective surgery
10 days after last dose of these drugs.
 6.antiplatelet drugs
 In past days high dose aspirin
(650mg/day)used is stopped 1 wk b/f surg
 In emergency no time to stop aspirin ,so
platelet transfusion given prior to surgery.
 In nowadays low dose aspirin(81mg or100mg/day) used
in cardiac patients
 Stopping of aspirin causes ischemia,so continue for all
surgeries except plastic,retinal surgeries where it
stopped 48 hrs prior to surgery.
 ciopidogrel: irrespective of dose it is stopped 7days
prior to surgery.
 Ticlopidine:it is stopped 14 days prior to surgery.
 Eptifibatide:it is stopped 8hrs prior to surgery.
 NSAIDS:continued except for plastic and retinal surgery
where it stopped 48 hrs prior to surgery.
 ANTI HTN DRUGS:
 All drugs continued with morning dose with sip of
water,except ACE inhibitors ,AT antagonists,where
morning dose is withheld.
 Studies found higher incidence of significant
hypotension in pts with morning doses of ACE
inhibitors,AT inhibitors.
 ANTI ANGINAL DRUGS:
 All drugs continued with morning dose except
antiplatelets.
 ANTI DEPRESSANTS:
 MAO-A inhibitors:to be stopped 3 wks
before surgery
 MAO-B inhibitors,reversible MAO
inhibitors,tricyclic anti depressants all
other anti depressants can be continued.
 ANTI EPILEPTICS:
 Continued morning dose with sip of water
 LITHIUM:
 To be stopped 48 to 72 hrs before surgery.
 Lithium enhances block produced by muscle
relaxants.
 LEVODOPA:
 Continued with morning dose otherwise
withdrawal cause muscular rigidity
 β blockers to be continued.succinyl choline and
halothane cautiously used.
 5. Antihypertensives:
should be continued as such with
morning dose to be Taken with sips of
water.
6. Antidepressants:
MAO-A inhibitors : Stop 3 weeks before.
7. Antiepileptics: to be continued as
such with morning dose .
 8. Lithium: stop 48-72hrs before
surgery.
 9. Levodopa: continued as such with
morning dose .
 10.Steroids: If the patient has steroid for
more than 1week in last one year then
intraoperative replacement with
Hydrocortisone is necessary.
 11. other drugs to be continued:
beta-blockers, digitalis,
antituberculous drugs ….
 GENERAL EXAMINATION:
Look for anaemia, jaundice, clubbing,
brusies, petechiae, dehydration,
organgomegaly including thyromegaly.
Elective surgery should be performed only if
Hb% is >10 gms%
Otherwise blood should be kept ready for
transfusion.

Record vital signs

SYSTEMIC EXAMINATION:
CVS:
1.Pulse rate for I minute
2. blood pressure
3. Presence of murmurs
4. 3rd & 4th heart sounds
5. Jugular venous pulsations
6. Signs of congestive heart failure
( cold calmy skin, poor peripheral
pulsations, edema feet, hepatomegaly,
gallop rythm, basal crepts.)
2.RESPIRATORY SYSTEM:
Look for equality of breath sounds on both
sides.
note all additional sounds ( rales,ronchi,…)
3. CNS:
Examine for sensory & motor deficits
This is important in medicolegal cases.
Any deficit in post operative period may be
attributed to anaesthetic technique esp.
regional techniques.
 4.Examination of Spine:
If a decision has been made to use
regional anaesthesia,
the area selected for nerve block, spinal,
epidural or caudal anaesthesia is
examined.
Spinal deformities, abscess near the site of
regional techniques should be noted.
5. Dental examinations:
Look for caries teeth, loose teeth, absent
teeth or dentures.
 AIRWAY ASSESSEMENT:
This includes
1.mouth opening
2.neck movements ( flexion ,extension)
3.thyromental distance
( is the distance from thyroid notch to mental
prominence when the neck is fully
extended.)
> 6.5 cm  normal
6 – 6.5 cm difficult intubation
< 6cm  laryngoscopy is impossible
MALLAMPATI’S GRADING:
For assessment of adequate mouth
opening.
Class 1: Faucial pillars, soft palate, uvula
seen
Class 2 : Faucial pillars, soft palate seen
but not uvula
Class 3: Only soft palate seen
Class 4: Only hard palate seen
 MALLAMPATI’S GRADING:
 Bed side tests:
 1. Breath holding time:
Patient is asked to hold breath after full
inspiration.
Normal -- >25 sec
Borderline -- 15 to 25 sec
< 15 sec indicates severe diminished
cardiorespiratory reserve

2. Match stick test:

the patient with normal respiratory reserve
should be able to blow off the match stick from
a distance of 15 cms
PYHSICAL STATUS (ASA)
CLASSIFICATION:
Class 1: a normal healthy person.
Class 2: pt with mild systemic disease
Class 3: pt with severe systemic disease
that limits activity but not incapacitating.
Class 4: pt with incapacitating systemic
disease that is a constant threat to life.
Class 5: moribund pt who is not going to
survive for more than 24hrs with or without
operation
Class 6: brain dead pt.
 INVESTIGATIONS:
1. URINE ANALYSIS:
Urine for albumin, sugar, casts, should be
performed in every pt.
it is inexpensive & may reveal undiagnosed DM,
or presence of UTI.

2.Full blood count:

includes RBC, WBC, Platelet counts.
Hb%. Blood grouping & typing,
Coagulation profile (BT,CT,PT,APTT)
NOTE:
 minimum number of normally functional

platelets to prevent surgical bleeding

should not be less than 50,000/mm3.
 Pts, with ethnic origin should be screened

for sickle cell Hb,

 3. Fasting blood sugar:

in diabetics
in pts on corticosteroids
4. serum creatinine & electrolytes:
in Hypertensives, renal disease, diabetics.
pts on digoxin & diuretic therapy
5. Liver function test: chronic alcoholics
6. ECG: 12 lead ECG is recommended for
all pt more than 35 yrs of age.
7. Chest x-ray: COPD, malignancy
8. Pulmonary Function Tests:
9. Screening for HIV, HbsAg is compulsory
PRE-OPERATIVE INSTRUCTIONS:
1. Nil orally for 8hrs

2. Artificial dentures, limbs, eyes, contact

lens should be removed
3. Jewellery, lipstick, nailpolish to be
removed as they can obscure
cyanosis.
4. Good oral hygeine

5. Informed consent

6. Premedication to be given.
 POSTPONING SURGERY FOR
CLINICAL REASONS:
-Acute URTI: for atleast 2 weeks as there
is increased predisposition for
laryngospasm,…
-Co existing medical diseases not under
control.
-Recent ingestion of food.
-Failure to obtain consent.
 EMERGENCIES:
There are few emergency situations which
demand immediate surgical intervention
without regard to pts situation.
They are
airway obstruction,
uncontrolled heamorrhage,
cardiac tamponade,
tension pneumothorax,
raised ICT
PREMEDICATON:
Premedication refers to the
administration of drugs in the period
1-2 hrs before induction of
anaesthesia.
Objectives:
1. Sedation
2. Amnesia
3. Analgesia
 Objectives:
4. Smoother, Easier induction of
anaesthesia
5. Reduction in the amount of drug
needed for anaesthesia.
6. Decreased undesirable reflexes
7. Diminished secretions in URT
8. Inhibition of nausea & vomiting
 1. Benzodiazepines like Diazepam,
Midazolam, lorazepam produce not only
anxiolysis & sedation but also good
amnesia.
 2. Anticholinergics:

to control secretions.
Atropine , Glyocopyrrolate, Scopalamine.
Glycopyrrolate is preferred in adults as it
does not cross blood brain barrier.
3. Antiemetics:
Metaclopramide, ondansetron, Hyoscine
 4. Opioids:
.used to provide analgesia
.to attenuate cardiovascular response
to laryngoscopy & intubation.
5. Antibiotics:
Best time is 1-2hrs before surgery.
HAVE A
NICE DAY