JAFMC Bangladesh 2005, June; 1: 27-31

Rabiul et al… Pre-anaesthetic incidental detection of systemic diseases

Rabiul M Alam1, Mahbubul M Alam2, Zahurul M Islam2 Abstract Purpose: Pre-anaesthetic assessment provides the patients’ preoperative physical status, existing medical conditions and their severity. Peri-operative morbidity and mortality are reduced by preanaesthetic optimisation of the patients. This prospective study was aimed to find out the incidence of detection of the pre-existing systemic diseases which were not diagnosed earlier. Method: A total of 2,086 indoor patients were studied during pre-anaesthetic assessment who were from all age-groups and of both sexes requiring routine surgical procedures under any type of anaesthesia. Check-up was carried out basing on history, physical examinations and investigation reports. The numbers of incidentally detected diseases were tabulated, analysed and compared with that of those pre-existing diseases, prevailed in the population. Result: The major incidental findings of diseases were: conduction heart block [18.75%], chronic obstructive pulmonary disease (COPD) [15%], anaemia [11.62%], ischaemic heart disease (IHD) [5.55%], and some other conditions like bronchial asthma, systemic hypertension, peptic ulcer disease (PUD) and drug allergy. The findings were statistically significant (p<0.05) in respect of conduction defects, COPD, anaemia, IHD, PUD and drug allergy. Conclusions: The findings revealed a possibility of increased peri-operative morbidity and mortality if meticulous and proper attention was not given while preparing the patients for anaesthetic procedures. Thus it was concluded that every hospital must run an effective anaesthesia out-patient department with the capability of careful and efficient check-up system to detect the undiagnosed diseases during pre-anaesthetic assessment for safe anaesthesia. Key words: pre-anaesthetic assessment, P/A checkup, incidental detection, systemic disease. Introduction Surgical mortality and morbidity are not only the consequences of the surgical procedure itself, but also of the patient’s preoperative physical status. The preoperative anaesthetic visit is aimed primarily at detecting these medical conditions and assessing their severity. Subsequent preoperative optimization of the patient’s condition reduces perioperative and
1 2

anaesthesia-related risks [1]. The preoperative anaesthetic visit also serves to guide the most appropriate anaesthetic technique and to provide patient information. Medical assessments enable physicians to reduce morbidity by obtaining health status and planning peri-operative management.

Department of Anaesthesia, Combined Military Hospital, Chittagong, Bangladesh. Department of Anaesthesia, Combined Military Hospital, Dhaka, Bangladesh. Corresponding author: Dr. (Lt Col) Rabiul M Alam, MBBS, MCPS, FCPS; Department of Anaesthesia, Combined Military Hospital, Chittagong cantonment, Chittagong, Bangladesh. E-mail: rabiuldr@gmail.com


JAFMC Bangladesh 2005, June; 1: 27-31

Rabiul et al… Pre-anaesthetic incidental detection of systemic diseases

Peri-operative morbidity and mortality increase with the severity of pre-existing diseases [2]. Preoperative evaluation is an essential screening to ensure that the patient is in the best possible physical condition before surgery [3]. During pre-anaesthetic assessment, if proper attention is not ensured, there are chances to remain some systemic diseases undetected. Failure to undertake this activity may place the patient at increased risk of peri-operative morbidity or mortality. Materials & methods A total of 2,086 indoor patients proposed for various type of routine surgical procedures of all ASA classes and of both sexes were included in this prospective study. With the approval of local ethical committee the study was conducted in the Anaesthesia OPD of a Combined Military Hospital in Bangladesh. Patients scheduled to undergo any type of anaesthesia were included. Obtaining detailed history, performing relevant physical examinations, evaluating investigations results, enormous

endeavour were there to find out any undiagnosed systemic disease. Results Demographic data of all age group patients are presented in Table 1. The total number of patients was 2,086, amongst which adults predominated. Out of 2,086 patients 1,379 (66.1%) were adult, 493 (23.63%) were from paediatric age group and 214 (10.25%) were geriatric patients. Male were 55.6% and 44.4% were female. Table 2 shows the proposed variety of surgical procedures, amongst which laparotomy (16.34%) was predominant. Table 3 shows the numbers of incidentally detected diseases, which were compared with that of those pre-existing diseases. The incidental findings of diseases were: conduction heart block (18.75%), COPD (15%), anaemia (11.62%), IHD (5.55%), bronchial asthma (1.61%), hypertension (1.3%), and some other conditions like peptic ulcer disease and drug allergy. The findings were statistically significant (p<0.05) in respect of conduction defects, COPD, anaemia, IHD, PUD and drug allergy.

Table 1: Demographic Data Age Paediatric Adult Geriatric Total No of case 493 1,379 214 2,086 Percentage (%) 23.65 66.10 10.25 100 Sex Male Female 368 125 675 704 117 97 1,160 (55.6%) 926 (44.4%)

Note: Total no of patients was 2,086; in which adults predominated amongst the age groups.


JAFMC Bangladesh 2005, June; 1: 27-31

Rabiul et al… Pre-anaesthetic incidental detection of systemic diseases

Table 2: Types of proposed surgical procedures

Proposed types of Surgery Abdominal/Laparotomy Gynaecological/Obstetric Orthopaedic Neurosurgical ENT Ophthalmological Urological Reconstructive Others Total

No of case 341 156 124 45 245 320 277 114 464 2,086

Percentage (%) 16.34 7.47 5.94 2.15 11.34 15.34 13.27 5.46 22.24 100

Note: Abdominal surgery was predominated among the types of proposed surgical procedures. Most of the varieties of surgery were included in the study. Table 3: Detected diseases Pre-existing No of detected diseases diseases 16 3 20 3 43 5 54 3 227 3 5 16 1 6 135 nil 11 nil 3 nil 10 nil 5 nil 4 nil

Name of Diseases Heart block COPD Anaemia IHD HTN PUD Hypersensitivity Diabetes Mellitus Congenital heart disease Valvular heart disease CRF CVA Thalassaemia

Percentage (%) 18.75 15 11.62 5.55 1.3



>0.05 <0.05


Note: Peptic ulcer disease and hypersensitivity were detected more than they were diagnosed earlier and highly significant.

Discussion Preoperative medical assessment relied primarily on accurate history-taking and physical examination from 1940 to

1960s. Then, laboratory tests were included in late 1960s, which can aid in optimizing a patient’s preoperative condition once a

JAFMC Bangladesh 2005, June; 1: 27-31

Rabiul et al… Pre-anaesthetic incidental detection of systemic diseases

disease is suspected or diagnosed. But it has several shortcomings like failure to uncover real pathological condition; the detected abnormalities do not necessarily affect patient care or outcome and their inefficiency in screening for asymptomatic diseases [4]. Practically, most abnormalities are discovered on preoperative assessment or even on admission screening for nonsurgical purposes. A conclusion was drawn from a long series of epidemiologic studies and controlled trials that preoperative assessment should be used primarily to ensure the optimal preoperative condition of a patient who has not received healthcare recently [5]. Studies showed that the history and physical examination are the best measures of screening for diseases [6]. There are at least three methods for organising preoperative evaluation efficiently. First, the surgeon, internist, family practitioner, or anaesthesiologist who sees the patient before a scheduled procedure can obtain the history and perform the physical examination. Second, a clinic can be set up in an outpatient facility to perform these two tasks early enough to ensure that laboratory tests or consultations can be obtained without delaying schedules. Third, a questionnaire answered by the patients can be used to indicate likely disease processes and appropriate laboratory tests [7]. At present in our set-up, an anaesthesia OPD is on operation to evaluate the cases preoperatively. With previously screened healthy patients, the anaesthetist, on the day of surgery, must check the results of screening and of other pre-operative testing. Any tests performed pre-operatively must be available

to and read by the anaesthetist. Patients likely to present anaesthetic problems should have been previously identified and seen by an anaesthetist prior to being scheduled for surgery. This is often done on an ad hoc basis but it is more efficiently carried out in an anaesthetic pre-operative assessment clinic [8]. Identification of potential problems during pre-anaesthetic assessment relies upon the knowledge, sincerity and commitment of the assessors, often augmented by following the screening protocols developed by the anaesthesia department. When a patient is in a special risk, should be referred to an appropriate specialist. Guidelines may be provided by the anaesthesia department for the surgical team to ensure that appropriate investigations are undertaken and suitable actions taken if problems are identified. The fundamental process of taking a detail history and performing a systemic clinical examination remains the foundation of preoperative assessment. There are many surgical conditions which have systemic effects, like bowel cancer may be associated with malnourishment, anaemia and electrolyte imbalance etc. These scenarios must be sought and quantified properly. The presence of coexisting medical diseases must also be identified together with the extent of any associated limitations to normal activity. In our study it is revealed that many systemic diseases like conduction heart block, COPD, anaemia, IHD, bronchial asthma, hypertension, and some other conditions such as peptic ulcer disease and drug allergies may remain undiagnosed even during indoor health care, which have a

JAFMC Bangladesh 2005, June; 1: 27-31

Rabiul et al… Pre-anaesthetic incidental detection of systemic diseases

significant impact on the course and outcome of anaesthesia and thereby on surgery. This work also alarms us to be more meticulous and curious during preanaesthetic assessment. The indoor physicians of surgical patients should take responsibilities to treat the ‘whole patient’. These conditions must be detected and optimised appropriately before hand in all routine cases to ensure a safe anaesthesia, to reduce morbidity and for satisfactory patient care service. Conclusion The importance of integrated practice in medical care is increasing day by day. A medical history can be provided by a number of sources because patients undergoing surgery move through a

continuum of medical care to which a primary care physician, an internist, an anaesthesiologist, and a surgeon contributes. The interns and resident physicians placed in indoor setup should show their keen interest in this respect and they have effective role to prepare the patients scheduled for surgery appropriately. A post-surgical satisfied patient is obviously an outcome of multidisciplinary contribution. The trends of motivating the undergraduate clinical students regarding these essential aspects should be more intensified. Detection of any coexisting systemic disease and subsequent necessary preoperative optimization not only aids the anaesthetic management but also saves the surgical team from any fatal outcome.

References: [1] Ausset S, Bouaziz H, Brosseau M. Improvement of information gained from the preanaesthetic visit through a quality-assurance programme. BJA 2002; 88: 280-3 [2] Vacanti CJ. VanHouten RJ, Hill RC. A statistical analysis of the relationship of physical status to postoperative mortality in 68,388 cases. Anesth Analg 1970; 49: 564-6. [3] Schern OD, Katz J, Bass EB. The value of routine pre-operative medical testing before cataract surgery. N Engl J Med 2000; 342: 168-75. [4] Roizen MF, Foss JF, Fischer SP. Preoperative evaluation. In: Miller RD, editor. Anesthesia. 5th ed. Philadelphia: Churchill Livingstone; 2000. p. 824-83. [5] Roizen MF. More preoperative assessment by physicians and less by laboratory tests (editorial). N Engl J Med 2000; 342: 204-5. [6] Delahunt B, Turnbull PRO. How cost effective are routine preoperative investigations? N Z Med J 1980; 92: 431-2. [7] Lichtor JL, Roizen MF. Preoperative assessment and premedication for adults. In: A Practice of Anesthesia, 7th edn, Arnold, London; 2003. p. 455-69. [8] Pre-operative Assessment: The Role of the Anaesthetist. The Association of Anaesthetists of Great Britain and Ireland; November 2001.


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