Pre- Anaesthetic Examination

Pre-operative Assessment Clinics (P.A.C.): nursing and surgical team may perform a baseline
assessment. Anaesthetist may be consulted in specific issues arise

 Symptomatic disease
 Previous anaesthetic difficulties
 Predicted anaesthetic difficulties eg obesity
 Hx or Family Hx of prolonged apnoea post anaesthesis etc.
 Plan for complex surgery

Assessment: Full Hx

Cardiovascular: I.H.D. & M.I, heart failure, HTN, valvular heart disease, arrhythmias, peripheral
vascular disease (D.V.T. & P.E.)

Risk of infarction post M.I. is significantly lower 6 to 8 weeks later.

HTN > 159/99 should be controlled before surgery

Respiratory: C.O.P.D, chronic bronchitis, emphysema, asthma, infection, restrictive lung disease.

Exercise Tolerance: treadmill & E.C.G.

 How far can you walk on the flat?

 How far can you walk uphill?
 How many stairs can you climb without stopping?
 Could you run for the bus?
 Are you able to do your shopping/housework?

General:

Indigestion/heartburn/reflux: risk of hiatus hernia & aspiration

Rheumatoid Disease: positioning

Diabetes: ↑IHD, renal dysfunction, neuropathy

Neuromuscular Disorders: poor respiratory function

Chronic Renal Failure: Drug choice

Jaundice: Altered drugs/coagulopathy, caution with opioids

History of Previous Anaesthetics:

Malignant Hyperthermia: abnormal Ca2+ release from the sarcoplasmic reticulum→ ↑muscle
activity & ↑heat production. Halothane & Suxamethonium are particularly associated. The risk may
be from 1:10, 000 to 1:40,000. Give Dantrolene as antidote.

Family Hx with anaesthetics is N.B.

Prolonged apnoea suggests a pseudocholinesterase deficiency.

Full Drug Hx & Allergy Hx: ask re. over the counter drugs, OCP & HRT.

Social Hx:

Smoking: ↑ Carboxyhaemoglobin →↓O2 Delivery

Nicotine can ↑Sympathetic activity → tachycardia, HTN & coronary artery narrowing
Chronic lung disease & carcinoma

↑ Risk of Post-op infections

Alcohol: > 50units per week → ↑ liver enzymes→↑tolerance to anaesthesia

Drug Abuse: IV Access Problems

Pregnancy: Last menstrual period & X-rays

Anaesthesia & risk of spontaneous abortion early in pregnancy.

Physical Examination:

Cardiovascular:

 Arrhythmias
 Heart failure
 HTN
 Valvular Heart Disease
 Peripheral Vascular Disease

Respiratory:

 Respiratory failure
 Impaired ventilation
 Collapse or consolidation, P.E.
 Additional or absent breath sounds

Nervous Sy:

 Any chronic disease, especially if it affects the cardio-resp system

Musculoskeltal:

 Movement

Airway: access!!

Look for limitation of the mouth opening, a receding mandible, position of the teeth & condition,
size of the tongue, any swollen tissue on the neck, deviation of the larynx or trachea, limited
flexion or extension of the cervical spine & TMJ.

Bedside Tests:

1) Mallampati Criteria: open mouth & protrude tongue, grade I to IV

2) Thyromental Distance: fully extend the neck & measure from the chin to the thyroid
prominence. <7cm suggests difficulty.`
3) Wilson Score: ↑weight, reduced head & neck movement, reduced mouth opening, receding
mandible/buck teeth.
4) Calder Test: patient protrudes their mandible. Lower incisors should lie ahead of the upper
ones. If they are aligned or behind, this suggests difficulty.
NICE Guidelines & Pre-op Tests:

16-59 for minor & intermediate surgery: there is no compulsory screening

Consider ECG, FBC & Blood Glucose

16-59 for major & major+ surgery: FBC & RFT are compulsory

Consider Blood Glucose, ECG & Clotting.

60-79 for minor & intermediate surgery: FBC is compulsory

Consider ECG, RFT & blood glucose

60-79 for major & major+ surgery: FBC, ECG & RFT are compulsory

Consider blood glucose, CXR & clotting screen

≥80 years for minor & intermediate surgery: ECG & FBC are compulsory

Consider RFT & blood glucose

≥80 years for major & major+ surgery: FBC, ECG & RFT are compulsory

Consider clotting, blood glucose & CXR.

Risks of Anaesthetics

Minor: failed IV access, damage to teeth or crowns, sore throat, headache, nausea & urine-
retention.

Major: aspiration, hypoxic brain injury, MI, CVA, nerve injury, chest infection, renal failure, death.

UK Confidential Enquiry (1987):

Overall perioperative mortality: 0.7%

Attributable to anaesthetic: 0.08%

Primary cause of mortality: 1 in 185,000 cases.

Pre-operative Risk Assessment

Goldman Cardiac Risk Index

Class I (0 to 5 points): 1% risk

ClassIV (≥26 points): 56% risk.