ANESTHESIOLOGY [SATURDAY SESSION] AY 21-22

PREOPERATIVE EVALUATION AND PREPARATION

Kristine R. Gonzaga, MD, DPBA, FPSA
5.05
17 JUL 21

TABLE OF CONTENTS Goals:

I. CASE .......................................................................................................1 Establish patient rapport and improve the patient-physician
A. Salient Features .................................................................................1 relationship.
II. Preoperative Visit .....................................................................................1
III. Anesthesia-Focused History and PE .......................................................1
Provide the patient information regarding the procedure and
A. History ................................................................................................1 instructions prior to the procedure
B. Physical Examination .........................................................................2 Detect perioperative risk
C. Physical Examination: Airways ..........................................................2 To provide the pt. with an estimate of the anesthetic risk
IV. Laboratory Exams and Diagnostic Studies .............................................3 Focus on the most common and most serious effects of the
A. Laboratory Exams ..............................................................................3
V. ASA CLASSIFICATION ...........................................................................3 anesthetic used
VI. PREPARATION FOR SURGERY ...........................................................4 Accomplish written informed consent for the proposed
A. Fasting Guidelines .............................................................................4 anesthetic plan from the surgical patient
B. IV Fluids and Blood Reservations ......................................................4 Develop appropriate anesthesia management plan in the
C. Maintenance Medications ..................................................................5
D. Preoperative Medications ..................................................................5
context of the overall surgical and post-op plan.
Also provides the patient with psychological support.
The preoperative visit results in a summary of all pertinent
MUST KNOW BOOK LECTURER
findings, including:
Detailed medical history
This trans is based solely on the case discussion with Dr. Kristine Gonzaga. Current drug therapy
Supplemental notes in gray are lifted from the Batch 2021 trans. Complete PE
I. CASE Laboratory and specific testing results
60 y/o Female III. Anesthesia-Focused History and PE
Weight: 75 kg
Height: 5 ft. 4 in. A. History
Chief Complaint: 3x3 cm breast mass on the right breast History of Present Illness
History of Present Illness Important to take note of the concise history behind the patient’s
Fine needle aspiration biopsy (FNAB): (+) invasive ductal medical condition (i.e., invasive ductal CA of the (R) breast)
carcinoma of the right breast Where is the mass?
Was then scheduled for Modified Radical Mastectomy (MRM) Ask the patient to pinpoint the exact location
on the R and referred for anesthesia. When did it appear?
Past Medical History Is it painful or tender?
(+) Diabetes Mellitus Are there associated symptoms (e.g., skin changes, weight
Maintained on Metformin (500 mg, twice daily) loss, pain)?
Good blood sugar control Tumor characteristics (benign or malignant)
Physical Examination Dictate the type of anesthetic to be used: generalized or
Table 1. Airway Examination regional
Examination Finding Review of Systems
Mallampati Scoring Type 1
Thyromental Distance 4 fingerbreadths Symptoms of metastasis
Mouth Opening 3 fingerbreadths Table 3. Sites of metastasis of breast cancer and associated symptoms
Neck Mobility Adequately mobile Organ Symptoms
Bones Back or leg pain
Anesthetic Plan: General Endotracheal Anesthesia Liver Abdominal pain, jaundice
A. Salient Features Lungs Shortness of breath, cough
Table 2. Salient Features Past Medical History
Subjective (+) Subjective (-) Comorbidities (cardiovascular, pulmonary, hematologic, CNS)
60 y/o female N/A Ask about metastasis for pain management and to decrease
Diabetic, good sugar control the risk of spreading the tumor.
(Maintained on Metformin 500 mg/tab, bid) i.e., breast cancer is associated with epidural spread
Objective (+) Objective (-) Current medications and dosage
Weight: 75 kg N/A Especially true for those with bleeding problems
Height: 5 ft. 4 in. Allergies to food, medications, etc.
BMI: 28.4 (Asia-Pacific: Obese) Most common medication allergies: penicillin, NSAIDs
3x3 cm (R) breast mass
FNAB: invasive ductal ca, (R) breast mass Surgical History
Mallampati Scale 1 Type of surgery
Thyromental distance: 4 fingerbreadths e.g., open appendectomy or laparoscopic
Mouth opening: 3 fingerbreadths Ask surgeon about the duration, location, and incision
Adequately mobile neck Unruptured AP: Rocky Davis
II. Preoperative Visit Ruptured/peritonitis/intestinal obstruction: midline
infraumbilical or subcostal
Initial step in preparing a patient for surgery
Midline incision usually makes use of straight general
Assesses and communicates a patient’s pre-anesthesia medical
endotracheal anesthesia or combined epidural with
comorbidities.
generalized anesthesia
Laparoscopic: usually 3-4 stab wounds/ports
GROUP 4H Page 1 of 7
 ANES - Friday 5.04 – Respiratory Physiology (16 JULY 2021) Page 2 of 7

Prior anesthetic records Hematologic

Type of anesthetic used
Adverse reactions or complications from the anesthesia Possible edema
Post-transfusion reactions Bruising
Possibility of difficult airways Anemia
d/t inherent anatomic problem or obesity C. Physical Examination: Airways
Makes the anesthesiologist more cautious about the Essential for the proper management of patients requiring
technique they will use. advanced airway management
Family History Mallampati Score
Ask the patient if there are first-degree relatives who have Checks for ease of intubation
cardiovascular, pulmonary, and hematologic conditions. Procedures
| Malignant Hyperthermia Patient position: upright, mouth open in the widest diameter
High mortality and morbidity rate for the patient undergoing Instruct the pt. to show tongue with no phonation
generalized anesthesia for MRM. Table 4. Mallampati Scoring
Ask first-degree relatives if they have had adverse reactions Class Structures Visualized
to generalized anesthesia during past major surgeries. I Full visibility of tonsils, uvula (base to tip), and soft
Presentation of MH: and hard palate; easiest to intubate
During or after the procedure, the patient presents with The patient falls under this class.
fever (dangerously high body temperature), muscle II Visibility of hard and soft palate, upper portion of
rigidity or spasms, and a rapid heart rate. tonsils, and > 50% of uvula
Triggers: inhalational anesthetics with depolarizing III Soft and hard palate and base of uvula are visible
neuromuscular blocking agents – succinylcholine (halothane) (< 50% of uvula); moderate difficulty
Specifically: liquid type (at room temp) IV Only hard palate visible; hardest to intubate
Alternative to succinylcholine: nondepolarizing agents Hard Soft
Alternative to inhalational anesthetics: palate palate Uvu la

Propofol infusion for induction and maintenance

Personal and Social History
Smoking
Nicotine affects the following:
Vital signs: increased BP and HR
Decreased ciliary function
Decreased oxygenation (curve shifts to the left)
Increased risk for aspiration
Class I Class II Class III Class IV
Alcohol Intoxication
Affects anesthetic requirement • Class I : Uvula, fauces, soft palate , pillars visible.
Chronic alcoholic drinkers will increase the anesthetic • Class II · Uvula, Soft pa late , fauces visible.
requirement while acute alcohol drinkers will decrease it. • Class Ill Base of uvula visible, Soft palate,
• Class IV : Only hard palate visible
Illicit Drug Use
Figure 1. Mallampati Classification and Scoring.
Methamphetamine (shabu) increases vital signs and
affects anesthetic requirement: Additional notes:
Acute: promotes release of catecholamines Uvula – most important structure
increased requirement to normalize BP and HR Class III and IV – ready gadgets
Chronic: less anesthesia Induce sleep before intubation.
May be done awake if intubation is really difficult.
Menstrual and Obstetric History
Thyromental Distance
MIDAS
Gravidity and Parity Landmarks: tip of the thyroid cartilage to the mentalis muscle
Manner of delivery
Anesthetics used
B. Physical Examination
General and Vital Signs
Check consciousness, estimate GCS Thyrom ental distan ce
Vital signs if they are stable or not Tip of thyr01d cartJlaQB tD the
Fifth VS in anesthesiology: pain tip r:I the chin ( mentun)

BMI – obesity may cause a problem during intubation

Possible evidence of a hematologic disease (e.g., petechiae,
bruising, clinical evidence of anemia)
CNS and Spine
Motor and sensory function
Skin infections, lesions Figure 2. Thyromental distance measurement. Measure from the tip of the
Spinal abnormalities and intervertebral spaces thyroid cartilage to the tip of the chin (mentum).
Pulmonary NV: > 6.5 cm or > 4 fingerbreadths
Thoracic shape, chest expansion Anything less will make it a difficult intubation.
Breath sounds Patient position:
Upright, neck hyperextended, mouth closed.
Cardiovascular Lower Mallampati class, greater thyromental distance easier
Do inspection, palpation, percussion, and auscultation intubation.
Note for presence of murmurs
Check for pulses and venous access sites
 ANES - Friday 5.04 – Respiratory Physiology (16 JULY 2021) Page 3 of 7

Other Airway Parameters for Easier Intubation A. Laboratory Exams

Mouth Opening Complete Blood Count with Platelet Count
NV: > 3 fingerbreadths Routinely done to establish a baseline.
aka inter-incisor distance or TMJ mobility Specifically: hemoglobin and hematocrit
Ask patient to insert their fingers in their mouth perpendicular Assesses for blood loss.
to the teeth. Hematocrit may also predict mortality.
Contributors to small mouth opening: dentures, deformities Blood Typing
of the oral cavity, limited TMJ mobility (e.g., TMJ pain)
Cervical Spine Mobility In cases of blood loss that may warrant transfusion.
Adequately mobile neck FBS and HbA1c
NV: > 30 degrees from neutral To monitor glucose control since the patient is a diabetic.
(+) neck osteoarthritis may limit neck mobility, thus making the
Kidney Function Tests
patient harder to intubate.
Instruct the patient to extend and flex their neck (paki-tungo BUN, Creatinine
ang ulo, tapos idikit ang baba sa dibdib), then measure the Check for target organ damage secondary to DM.
degrees from normal. Others
Neck Circumference Electrolytes
NV: < 40 cm If the patient is taking medications like thiazides, or if
A neck circumference of > 40 cm may indicate a morbidly experiencing nausea and vomiting.
obese patient; thus, they may be difficult to intubate. COVID-19 RT-PCR
Dentition Necessary screening for patients during the pandemic.
If there is no dentition, intubation will be easier; however, there
may be a leak when the need for face mask ventilation arises. Radiographic Studies
For face mask ventilation: Chest X-ray, ECG, and 2D Echo
With teeth: easier because they allow conformation to the If the patient is post-MI
shape of the face. Also indicated for those with anginal episodes
No teeth: there will be a leak. V. ASA CLASSIFICATION
Laryngoscopic Grading The American Society of Anesthesiologists (ASA) Physical
Table 5. Laryngoscopic Grading Status Classification System was developed and is classified into
Grading Structures Visualized 6 categories.
I Glottis is completely visible A time-tested, reproducible tool used to assess and communicate
II Posterior commissure/posterior portion of the a patient’s pre-anesthesia medical comorbidities.
laryngeal aperture Used alone, it does not predict the perioperative risks.
III Only the epiglottis is visible If used with other factors (e.g., type of surgery, frailty, level of
IV Only the soft palate is visible deconditioning), it is helpful in predicting perioperative risks.
Table 6. Updated ASA-PS Classification placed in Appendix,
p. 7
ASA I
Healthy patient that does not smoke and consumes minimal to
no alcohol intake
Pediatrics: healthy patients with a normal BMI percentile for age
Example: 20 y/o, no comorbids, and with good airway
ASA II
Adult patient with mild systemic disease
Current smoker, social alcoholic drinker
Pregnancy
Obesity (30 < BMI < 40)
Well-controlled DM/HTN, mild lung disease
Examples:
30 y/o non-smoker, non-alcoholic drinker but with clinical
depression on maintenance for medications, for excision
Figure 3. Visualization of structures for laryngoscopic grading. 20 y/o occasional alcoholic drinker or smoker (1-2 sticks/day)
| Category is… Difficult Intubation 10 month old for eye examination under anesthesia
Fist-sized tumor at the trachea (obstruction) The patient in the case is classified under ASA II.
Calamansi-sized tumor in the larynx 60 y/o F with controlled DM
Motor vehicle accident (MVA) with cervical fracture ASA III
Can’t hyperextend the neck of these patients; else, it might Patient having severe systemic disease.
lead to a high spinal cord injury. Includes patients who have substantive functional limitations
Down Syndrome patient (i.e., one or more moderate to severe diseases, or those with
Atlanto-axial subluxation and macroglossia poorly controlled conditions).
Full-term pregnancy Examples:
Progesterone levels make the mucosa friable easy bleeding
50 y/o, stable angina, for phacoemulsification
BMI: 40
60 y/o herniorrhaphy, post-angioplasty
Mallampati Type IV
Unruptured cerebral aneurysm without mass effect from
(+) neck osteoarthritis; ROM: 20 degrees
intracranial bleed
IV. Laboratory Exams and Diagnostic Studies 1 month old, preterm, 58 weeks postconceptional age
Done as part of the perioperative assessment. < 60 weeks: more prone to apneic episodes under
Individualized according the patient’s condition and procedure to anesthesia.
be undergone.
 ANES - Friday 5.04 – Respiratory Physiology (16 JULY 2021) Page 4 of 7

ASA IV | Do we still need fasting for regional anesthetic procedures?

Severe systemic disease that is a constant threat to life. ASA members strongly agree that fasting from the intake of a
Unstable angina, poorly controlled COPD, symptomatic light meal of 6 or more hours before elective procedures
congestive heart failure, recent MI or stroke. requiring general anesthesia, regional anesthesia, or
Examples: procedural sedation and analgesia should be maintained.
Post-angioplasty 2 months ago B. IV Fluids and Blood Reservations
Hemodialysis without funds 2x/week
Intravenous Fluids
ASA V
Preoperative preparation may consist of infusions of crystalloids,
Moribund patients (at point of death) who are not expected to colloids, or a combination of both.
survive beyond the next 24 hours without the operation.
Table 7. Crystalloids vs Colloids
Ruptured abdominal aortic aneurysm, massive trauma, extensive Crystalloids Colloids
intracranial hemorrhage with mass effect High molecular weight
Aqueous solutions of ions
ASA VI substances (proteins or large
(salts), with or without glucose
Declared brain-dead patients whose organs are being removed polymers)
for donor purposes. Rapidly equilibrate
Mostly remain intravascular
Why is there a need for an anesthesiologist: Distribute through the ECF
Ethical Equally effective in restoring
Helps maintain plasma colloid
To ensure that the organs are well-perfused and viable for intravascular volume when given
oncotic pressure
in sufficient amounts
harvest.
Half-life: 20-30 mins Half-life: 3-6 hrs
| ASA PS-E Examples: Examples:
The addition of the letter “E” to the ASA PS denotes an Lactated Ringer’s Solution Dextran
emergency surgical procedure. NSS Hydroxyethyl starch
An “emergency” is defined as “when the delay in the treatment 5% dextrose in water (D5W) Human albumin
of the patient would lead to a significant increase in the threat Hypertonic 3% saline 5% plasma protein fraction
to life or body part.”
Insertion of IV Access
Example:
Emergency caesarian: ASA 1-E May be done at night or early in the morning, provided that the
20 y/o no comorbids and with good airway for emergency patient is not dehydrated and does not need IV medications.
appendectomy: ASA 1-E In the case of our patient, IV can be inserted in the morning
Hemodialysis w funds 3x/week, emergency DKA: ASA 3-E before the procedure so that she can sleep comfortably.
Emergency appendectomy post-angioplasty 2 weeks ago: If the patient already has an IV access, check for its patency
ASA 4-E (i.e., not leaking or clogged)
35 y/o ruptured triple AAA for emergency repair: ASA 5-E Indications for IV insertion the night before:
Dehydrated
VI. PREPARATION FOR SURGERY Need IV medications
Expected blood loss (done as pre-loading w/ fluids or blood
A. Fasting Guidelines products)
Fasting reduces the volume and acidity of a patient’s stomach
| IV Insertion for a Patient Undergoing MRM
contents.
Put the IV on the contralateral side of the procedure for better
This reduces the risks of regurgitation and pulmonary aspiration
and easier operation.
as a result of anesthesia induction.
Placing the IV on the ipsilateral side lymphedema
Anesthetics can cause aspiration and regurgitation during
MRM involves removal of the axillary lymph nodes
induction because the protective airway reflexes are lost.
If bilateral MRM: place IV in the lower extremities
Pulmonary aspiration: inhalation of oropharyngeal or gastric
If expert: place central line at the IJV
contents into the larynx and the respiratory tract.
| Sample Cases for IV Insertion
Aspiration of solid matter can cause hypoxia by physical
70 y/o M, (+) HTN and DM, for colon surgery for bowel enema
obstruction
(labatiba)
Aspiration of gastric fluid can cause pneumonitis with the
Decision: insert IV access early
syndrome of progressive dyspnea, hypoxia, bronchial
If postponed:
wheeze, and patchy collapse, consolidation on CXR, or all.
Leads to electrolyte imbalance (hypokalemia)
Table 6. Fasting Guidelines Since the pt. has HTN and DM too, they may have
Hours Before Surgery Type of Food/Drink hypoglycemia and dehydration
8 hrs Regular or heavy meals 10 month old for abdominal surgery, NPO 8 hours
Light meals, formula milk, non-clear Insert IV early to make sure the pt. is euvolemic prior.
6 hrs
juices, gum, hard candies Prone to fluid loss, hypoglycemia, dehydration
4 hrs Breastmilk
Clear liquids only (water, iced tea, apple Blood Reservations, Consents, and Advanced Directives
2 hrs
juice, etc.) Discussed in the preoperative period.
Oily foods (e.g., crispy pata, mayonnaise) are classified under Involves patient preferences and acceptance, or
regular or heavy meals. Declining various blood components and/or blood conservation
Allowable maintenance medications can be taken 2 hours prior. modalities.
Complications of Prolonged Fasting Pre-op The pre-anesthetic consultation provides an opportunity to
assess and address risks for bleeding and to evaluate for
Prolonged fluid fasting:
possible interventions, reducing need for transfusions.
Anxiety
Baseline hemoglobin measurement: obtained in:
Dehydration
Pts. undergoing major surgical procedures that have
Post-operative nausea and vomiting
significant expected blood loss (> 10% chance of needing a
Prolonged fasting (more frequently seen in children):
transfusion or > 500 mL blood loss).
Hypoglycemia
Individuals likey to have preoperative anemia (e.g., due to a
Hypovolemia
known underlying condition) – unless it is a minor procedure.
 ANES - Friday 5.04 – Respiratory Physiology (16 JULY 2021) Page 5 of 7

Typing and cross-matching tests ensure the availability of ACEIs/ARBs

appropriate blood products before procedures with expected Promote anesthesia-induced hypotension
major blood loss. Held 11 hours prior to surgery to reduce the risk
Notify blood bank of the approximate number of units likely to Herbal Medications and Food Supplements
be required based on known blood loss. Can interfere with anesthesia and surgery, especially those
| Sample Scenarios for Blood Reservations containing garlic, gingko, and ginseng, which have
Patient for hysterectomy with Hgb of 102: yes (request for anticoagulant properties.
blood) because of the nature of the procedure. Discontinued a week prior.
20 y/o, no comorbids, breast excision, starting Hgb 120: no To Continue
20 y/o MRM, starting Hgb 80: yes Beta-blockers
20 y/o MRM, ASA 1, starting Hgb 120: no Continued for high-risk patients undergoing major non-cardiac
Conservative cut-off for Hgb: 100 (can be as low as 80-90) surgery
Reduce ischemia by decreasing myocardial oxygen demand
Assess Fluid Responsiveness
due to increased catecholamine release
Preoperative IV fluids are needed for most emergency surgeries Anti-epileptic Drugs
and sometimes for elective surgeries because of extra fluid Risk for withdrawal if stopped abruptly.
losses and typically longer fasting times. Glucocorticoids
Accurate assessment of an individual’s fluid status can be Necessary to maintain optimal lung functions in patients with
difficult, but a careful hx and PE supported by bedside tests asthma.
should be sufficient to gauge fluid responsiveness for most. Risk for adrenal insufficiency if stopped abruptly
As long as additional IV fluids will increase cardiac output and Antithyroid Drugs
thus improve tissue perfusion. Withholding may impair symptom control of thyroid disease
There is fluid responsiveness when there is 10% or greater
increase in stroke volume. D. Preoperative Medications
Assessed using the passive leg raising technique: First step: establish the goals for the patient.
Transiently increases venous return in patients who are Need to have a specific purpose:
preload responsive. No specific checklist; always individualized according to the
Thus, it is a diagnostic test and not a treatment. patient’s case and needs.
Predictor of fluid responsiveness: helps identify pts. who Avoid giving unnecessary medications (avoid polypharmacy)
are on the ascending portion of their Starling Curve. Increases the chance of drug-to-drug interactions.
Will thus have an increase stroke volume in response to Multifactorial:
fluid administration. Health status of the patient (e.g., in pain? known comorbids?)
Patient positioned at 0°, then both legs are raised to 45°. Emotional status of the patient (e.g., increasing anxiety)
This returns a reservoir of venous blood back into the Surgical procedure to be done
central circulation relatively quickly (30-90 seconds). Ask about the length of the procedure and how this will
Table 8. Estimating maintenance fluid requirements affect the patient.
Weight Rate Anesthetic plans
For the first 10 kg 4 mL/kg/h Avoid drug-drug interactions.
For the next 10 kg Add 2 mL/kg/h e.g., benzodiazepines may enhance the hypnotic effect of
For each kg above 20 kg Add 1 mL/kg/h anesthetics.
Example: What are the maintenance fluid requirements for a Table 10. Decision-making for preoperative sedation
25-kg child? Type of Patient Sedation
Answer: 40 + 20 + 5 = 65 mL/h Unnecessary; may start in the OR
NOT restless or nervous
instead
C. Maintenance Medications Restless/nervous May sedate prior to the OR
Table 9. Decision on maintenance medications pre-op Obesity, Mallampati IV DO NOT sedate prior to the OR
Discontinue Continue Neck circumference >40 (may have obstruction); reassure
Anticoagulants Beta blockers Short thyromental distance while in the ward.
Oral hypoglycemic agents Anti-epileptic drugs DO NOT sedate prior to the OR
Monoamine oxidase Anti-Parkinson drugs Elderly with OSA (high risk of obstruction and
ventilation)
inhibitors Anti-dementia drugs
ACEIs/ARBs Glucocorticoids | Sample Scenario
Herbal medications and Antithyroid drugs 5 y/o, pediatric patient for circumcision under general
food supplements anesthesia. Is it recommended to sedate the pt. in the ward?
Answer: NO. Do it in the OR lobby. Sedate a few minutes
To Discontinue
before bringing the child in the OR.
Anticoagulants Pediatric patients: decreased oxygen consumption.
May increase the risk of bleeding Can lead to hypoxia if done in the ward.
However, in patients with high risk of developing MI, aspirin
may be given (benefits outweigh the risks) What pre-operative medications should be given to our pt?
Oral Hypoglycemic Agents Patient is a known diabetic and is obese.
Highly associated with metabolic acidosis under general Increased risk for gastroparesis (delayed gastric mobility)
anesthesia prone to aspiration
Held 24H prior to surgery Treatment:
Monoamine Oxidase Inhibitors PPIs (omeprazole)
Simultaneous intake of ephedrine and MAOI increase Promotility drugs (metoclopramide)
catecholamine levels in the blood, stimulating the sympathetic Anxiety
nervous system hypertensive emergency Normal response to surgery
Ephedrine: indirect sympathomimetic; activates alpha and Diminishing anxiety is a common major goal of pre-op meds.
beta-adrenergic receptors and inhibits NE uptake However, not limited to giving medications alone.
Tapered 2-3 weeks prior to procedure May also be established through good patient-doctor
rapport and talking and comforting the patient.
 ANES - Friday 5.04 – Respiratory Physiology (16 JULY 2021) Page 6 of 7

Pharmacological Treatment:
Benzodiazepines
Usually given
Diazepam, midazolam, lorazepam, flumazenil – have
amnestic effects and are known anticonvulsant (play a
role for patients who experience seizures).
Antihistamines
Diphenhydramine
Pain
Many pts. undergoing surgery usually come in due to pain.
Treatment:
Analgesics – for reduction of discomfort
Opioids (morphine, fentanyl) – consider first the
possibility of respiratory depression, orthostatic
hypotension, and nausea and vomiting.
NSAIDs

Opioid for moderate to severe pain

± Nonopioid
3 ± Adjuvant

Opioid for mild to moderate pain

± Nonopioid
2 ± Adjuvant

Nonopioid
1 ± Adjuvant
Figure 4. WHO Step Ladder for Cancer Pain.
When giving opioids, it is important to con
Post-operative nausea and vomiting (PONV)
Risk Factors:
Female, non-smoker, history of PONV, motion sickness,
and was given inhalational anesthesia.
Prophylactic Treatment:
Antiemetics (ondansetron) – usually given
Promethazine – curative
Ondansetron – preventive
Reduction of Airway Secretions, Bronchospasm Prevention
Usually needed for asthmatic patients.
Treatment: anticholinergics (atropine sulfate)
Increase pH of Gastric Contents
For delayed surgery because patients are in NPO.
Treatment:
PPIs (omeprazole) – used to increase the pH of the GIT
Anxiolytics – since anxiety may play a role in making
patients more acidic.

END OF TRANSCRIPT

REFERENCES
Group 4H (2021-2022). Clerks Case Discussion: Anesthesia Preoperative
Evaluation and Preparation. [PowerPoint Presentation]. Manila,
Philippines: Faculty of Medicine and Surgery, University of Santo Tomas,
ANES.
Gonzaga, K.R. (2021). Preoperative Evaluation and Management. [PowerPoint
Presentation]. Manila, Philippines: Faculty of Medicine and Surgery,
University of Santo Tomas, ANES.
Group 3 (2020-2021). Clerks Case Discussion: Preoperative Evaluation and
Preparation. [PowerPoint Presentation]. Manila, Philippines: Faculty of
Medicine and Surgery, University of Santo Tomas, ANES.
 ANESTHESIOLOGY [SATURDAY SESSION]
PREOPERATIVE EVALUATION AND PREPARATION
Kristine R. Gonzaga, MD, DPBA, FPSA
APPENDIX
Table 6. Updated ASA-PS Classification
ASA PS Aelult Ex11mplos,
Clsss1!1ca11on Def1nlt11:1n lnclud1119, bul not limrled
to,
A SA I Anorm 1-fealttly, noo-smoklng, no or
h11althy palient minimal alQQho.l u,;e
ASAII A patie.11 wlln Mlld diS<la$8S only wili'loul
mild sys1emfo subslan1ive functional
diS<lase llmitalrons. Current smijker,
soc! alcohol drinker,
pregn!!flcy, obesity
(30<SMl<40), well •
controUed DM,HTN, mild
ILJnQ d sease
.ASA HI Apatloot wlh Substanllve runcllonal
5e"ere limitaoons; One or more
systemic moderate to s8V<lre
disease a,seases. Poorly controlled
DM or HTN. COPD, morbid
obesity (BM I :.40), active
h1,1patms, aloohOI
depoodence or abuse,
implanted pacemaker,
moderate reduction ol
ejer;,tio11 !faction, ESRD
undergoing rngularly
scheduled di ysis, hislDry
(:>3 months) of Ml, CVA,
TIA, or CAD/stent:s,
.ASA IV A patleril wflh Rec.i,nt (<3 months) Ml,
severe CVA, TIA or CADMenls,
systemic ongo1ng cardiac iscl'lemla or
disease lha1 is severe Yl!lve dys,functi011,
a co.nstant s9\lere reduciion of ejootlon
lhreat !o life ifaciion, shock, sep,;is, DIC,
ARD or ESRD not
undergoing ragulartiy
5Chetluled diBly5i,;
ASAV AmorlbLmd Aup1ured
pa!ienl whO is ebdominal/lhoracic
not expected to aneurysm, massive trauma,
,;urvive without imracranial blee,d with m11ee
!he op!llatlon effect, lsdlemic bowel In the
f11ce of significant cardiac
pathotogy or muitlple
organ/system dysfuncuoo
ASAVI A declared
brain-dead
pacienl whooe
organs are
being removed
for dooor
purpo,ses
• Althoush presnancy ;snot a disease, the parturien t' s physiolosic state is sjgni/ican Uy altered from when the
woman rs not pregnant, hence the assignment of ASA 2 tor a woman with uncomplicated preg-nancy.
~'The addftion of •e denotes Emergency surgery; (An emergency is defined as existins when delay in treatment of
the patient would lead too sisni/icont increase in the threat to life or body part)
GROUP 4H
AY 21-22
5.05
17 JUL 21
Pediatric Examples , lncluellng but Obslelric Exampr.cs.
not L1m1te-d to: lnctLJding bLJt not Um1te-d
to,
Healthy {no acute or ctironic
•diefi!<!.,;e), normal BM I ~c1111lite tor
age
Asympromalic congenllal cardla~ Ni;,rmal preg,iancy·, we I
disease, well contmlled 0011trolled gestalioool HTN ,
dysrhythmias, asthma witnoul oontrolled preeclampeia
exacerbation, well controlled without severe realures,
epilepsy, 11Qn-in,;uln dependent diel-controllecl gestational
dlalletos mellltus, abru:irmal SMI DM.
percenlile ror age, mild/motlera!e
OSA, onoolOglc state in remission.
autism wi h mild limitations
Uncorrected stable congenlt cardmc Preectampsla with sev e
abnormality, as1hrna with !eai\Jres, gest<ltion.il DM
0xaoerbatlon. poorly oontrolled with oompllcatlons or l'ligh
epilepsy, in911lin dependenl diabetes insulin requirements, a
melmus, IIIOlt!kl obesity, malnutrition, tnrotnhopt,~ic di~eaS<l
severe OSA, onoologic slate, renal requiring anlicoagulatiori.
failwe, mll$Cular dystropl'ly, cyslie
fibrosis. hist()(}' of organ
tral1$jllantelion, brainlepinal cord
malformation, symptoma~c
hydroceph!llus, prernab.Jre inf8lll PCA
<60· weeks, autism wllh severe
limilatioos, metabolic disease, di!licvlt
airway, long term parenteral nulrllion.
Full lerm inlaflts <6 weeks of age,
Symptomalic congonltal cardiac Preectampsla with sev e
atmorrnality, OOflg,eslive he11r1 r ·1ure, feaiures cornpliceled by
active sequelae of pramatufiry. acute HELLP or other ac!Wttse
hypo~io-ischemic encephaJopathy, event, peripart\lm
sl'IOd(, S<lp.sis. disseminated card,omyopalhy w,l11 EF
lntrava.scular ooagulalion, automa!ic <40,
implantable careliollllrler-deflllrillator, uncorrecledloeoornpensa1eci
ventilator dependence, heart drsease, ac[IUireo or
endocrinopalhy, ,;evere trauma, con9E1nilel.
S9\IIH9 rosplratory distress, advanclld
oncologic state.
Massive lrauma, intracranial uterine rup ure,
hemorrh~e wilh m"ss effoot, patient
requiring ECMO, respiratory fal ure or
arresl, malignant h)'Pertensioo,
doco~l'ISaloo congestlv·e hean
failure, hepatic encephalopa1hy,
lschemic bowel or muiliple
Dr!lfill"syslem dysfuriction,
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