PREOPERATIVE

EVALUATION AND
RISK ASSESSMENT
Seminar presented by :
Amer Ahmad, Ahmad Bataineh, Ali Haider
26/10/2020
5TH Y/D1
PREOPERATIVE EVALUATION
PREOPERATIVE EVALUATION

The preoperative evaluation is an overall assessment of the patient's health

to identify operative risks that may influence the recovery period.
WHY IS PREOPERATIVE ASSESSMENT
ESSENTIAL ?
- To ensure the safety of anesthesia .
- To minimize the patient's surgical and
anesthetic mortality & morbidity risk in the
perioperative period.
- To ensure that the patient is in the best (or
optimal) condition.
 PREOPERATIVE EVALUATION

▪ Documentation of the condition(s) for which surgery is needed

▪ It offers the anesthetist an opportunity to define the patient's medical and surgical
problems
▪ Further investigation, consultation, and treatment can be arranged for patients
whose condition is not optimal.
▪ Perioperative risk determination and develop an appropriate perioperative care plan.
▪ The anesthetist can provide information and reassurance for the patient during this
stressful time
▪ Reduction of costs, shortening of hospital stay, reduction of cancellations and
increase of patient satisfaction.
▪ The preoperative visit should include the following steps:

1. Problem Identification
2. Risk Assessment
3. Preoperative Preparation
4. Plan of Anesthetic Technique

* Note : the preoperative visit is done one day prior to surgery

1. PROBLEM IDENTIFICATION

History 🡪 physical examination 🡪 laboratory investigation.

 HISTORY
The anesthetic history should include :
1. A brief history of present illness.
2. Current medications
3. Allergies and type of reaction.
4. Significant past medical history (all systemic review) & surgical history.
5. Past anesthetic history .
6. Family history of any anesthetic problem
7. Functional inquiry appropriate to the patient .
8. NPO status. (6-8h)
9. Specific questions directed at the identified problem list, attempting to assess the
severity of the problem, its associated disability, and the patient's remaining
physiological reserve
Note:
The anesthetist pays special attention to symptoms and disease related
to the cardiovascular, respiratory, and neuromuscular systems as they
will directly manipulate these systems during surgery.
it is important not only to identify symptoms, but also to document their
severity and to determine their stability or progress.
Patients with unstable symptoms should be postponed for optimization prior
to elective surgery.
 CARDIOVASCULAR:
▪ Patient with Ischemic heart disease are at risk for MI or in the peri-operative period

▪ Angina: new or has recently changed from previously stable pattern .

▪ A description of the patient's exercise tolerance .

▪ Patients with a history of a recent myocardial infarction (< 6 months) or unstable angina are
poor surgical candidates, with a high risk of significant morbidity or mortality .

▪ Valvular heart disease presents a special set of concerns to the anaesthetist .

▪ Consider the risk of subacute bacterial endocarditis (SBE) in these patients.

▪ In the preoperative visit, identify a past history ; of arrhythmia or symptoms suggesting the
need for a pacemaker.

▪ Hypertension (baseline blood pressures, what medications, any complications) .

 PULMONARY
▪ Anesthesia, surgery and postoperative analgesia all predispose patients
with COPD to respiratory depression, atelectasis, retained secretions,
pneumonia and respiratory insufficiency .
▪ asthma is at particular risk as manipulation of the airway and cold dry
anesthetic gases are potent triggers of intraoperative Asthma
▪ Determine the presence of cough and the color and amount of sputum.
▪ Ensure that there is no acute upper respiratory infection.
▪ Restrictive lung disease will be worsened by upper abdominal or
thoracic surgery, and place the patient at increased risk for
perioperative failure.
▪ Any disease process which leads to an altered control of
breathing (obstructive sleep apnea, CNS disorders, etc.) may
lead to profound respiratory depression from the drugs used in
the perioperative
▪ Smoking history (Pack year history, recent episodes of
bronchitis, sputum production) , The chronic smoker should
be encouraged to abstain from smoking for at least 8 weeks
prior to the operation,' but stopping smoking for even 24
hours may produce benefits in cardiovascular physiology and
carboxyhemoglobin levels.
NEUROMUSCULAR

▪ If the patient has an intracranial lesion, seek early signs and symptoms such
as headaches, nausea, vomiting, confusion and papilledema.
▪ Pituitary lesions may cause endocrine abnormalities.
▪ A history of or CVA's suggests significant cerebrovascular disease.
▪ The anesthetist should ask the patient about a history of seizures, and
determine the type, frequency and time of last occurrence , medication.
Avoid anesthetic drugs that are potentially epileptogenic (e.g. enflurane;
▪ The patient with a history of spinal cord injury is at risk for a number of
perioperative complications including respiratory failure, arrhythmias,
autonomic hyperreflexia, hyperkalemia, pathologic fractures and pressure
sores.
a) lower motor neuron lesions of any kind are at risk for unusual responses to
anaesthetic drugs and regional anaesthesia should be considered only after
careful documentation of the patient's nerve deficits.
b) Disorders of the neuromuscular junction such as myasthenia gravis,
myasthenic syndrome, etc., will cause unpredictable responses to
neuromuscular-blocking drugs.
c) Lastly, patients with muscular dystrophies and underlying myopathies are
known to have both an increased association with malignant hyperthermia
and an increased risk of postoperative respiratory depression
 OTHER CONDITIONS WHICH ARE IMPORTANT IF
IDENTIFIED IN THE MEDICAL HISTORY
▪ Patients with DM require careful management in the perioperative period, as the
stress of surgery and perioperative fasting can cause marked swings in blood
glucose.

▪ Increased risk of intra and postoperative complications, particularly hypotension

and infections

▪ Patients with thyroid disease may experience difficulties under anaesthesia.

Profound hypothyroidism is associated with myocardial depression and
exaggerated responses to sedative medications.

▪ Hyperthyroid patients are at risk for perioperative thyroid storm.

▪ Thyroid goitres may compress the airway and involve the recurrent laryngeal nerve
leading to vocal cord palsy.
▪ Patients with phaeochromocytoma are particularly challenging for the
anaesthetist, surgeon, and internist involved in their care. These patients are
at risk for extreme swings in blood pressure and heart rate in the
perioperative period, and require intensive preoperative therapy with
adrenergic blocking drugs.
▪ Patients at risk for adrenal suppression may not be able to increase their
own corticosteroid production to match the imposed stress of surgery. Its
depends on the potency and frequency of steroid dose and on the length of
steroid therapy.
▪ Patients with gastroesophageal reflux (GER), as well as those at risk for
GER, are prone to regurgitation of gastric contents and aspiration
pneumonitis during the perioperative period
note :
Anaesthetic Complications – Aspiration Pneumonitis). These patients should
receive anti-reflux prophylaxis preoperatively.
THE ELDERLY
▪ The elderly patients are generally recognized to be in a higher
perioperative risk group.
▪ the risk must be balanced against the potential for the patient
returning on an emergency basis.
▪ Perioperative morbidity and mortality are related to the extent of
coexisting disease.
▪ Emergency surgery in the elderly patient may lead to a four- to
twenty-fold increase in perioperative mortality.
▪ Delay in presentation and inadequate time for optimizing
coexisting disease place an increased burden on a patient lacking
the physiological reserve to tolerate major stress and surgery.
MEDICATIONS AND
ALLERGIES:
▪ A detailed list of the patients' medications and allergies is an
essential part of the preoperative assessment. Particular attention
should be paid to cardiovascular and respiratory medications,
narcotic analgesics, and drugs known to have significant side
effects or drug interactions.
▪ As a general rule, all cardiac and pulmonary medications and
most other necessary medications should be taken with sips of
water at the usual time, up to and including the day of surgery.
▪ Many "allergies" are simply anticipated drug side effects such as
nausea and vomiting, or adrenaline absorption from local
anaesthetic agents.
▪ True allergies to anaesthetics are unusual, but when present, can
be fatal
PRIOR ANAESTHETICS
▪ The patient undergoing anaesthesia and surgery should be
carefully questioned on their response to previous anaesthetics
and a family history of problems with anaesthesia.
▪ Investigate any complication or adverse reaction to prior
anaesthetics. Document the type of problem, as well as its
management and outcome.
▪ In the case of serious perioperative events, consult the old chart
to complete the history.
 FAMILY HISTORY
▪ All patients should be asked whether there are any known inherited
conditions in the family (e.g. sickle-cell disease, porphyria).
▪ Have any family members experienced problems with anaesthesia;
a history of prolonged apnoea suggests pseudocholinesterase
▪ deficiency and an unexplained death malignant hyperpyrexia
▪ Elective surgery should be postponed if any conditions are identified,
and the patient investigated appropriately.
▪ In the emergency situation, anaesthesia must be adjusted
accordingly, for example by avoidance of triggering drugs in a patient
with a family history of malignant hyperpyrexia.
 FASTING GUIDELINES PRIOR
TO SURGERY
▪ 8 h : after meal that include meat , fried or fatty foods .
▪ 6h : light meal ( toast crackers) or after ingestion of infant formula
or nonhuman milk
▪ 4 h: ingestion of breast milk
▪ 2 h : after clear fluids( water , black coffee, tea, carbonated
beverages , juice without pulp)
PHYSICAL
EXAMINATION
Ahmed bataineh
PHYSICAL EXAMINATION:
The physical Examination should focus on evaluation of:
1.Airway
2.CVS
3.RS
4.Any other system identified as having symptom or disease
from the history
5.If a regional anesthetic is planned, the appropriate anatomy is
examined.
 GENERAL ASSESSMENT
▪ Physical: Such obvious differences
Is the patient young and physically fit, or
will dictate the extent and
elderly incoherent.
intensity of
Mental:
alert, calm ,and cooperative, or unusually anxious
the examination and the time
required to
about their scheduled procedure.
The patient's mental listen to the patient's
Status (anxiety, depression) influences the type and concerns and provide
amount of preoperative medication reassurance.
required and may influence the
type of anesthetic technique used. There are three types
(local; numbs one small area pts still awake ,alert)
(regional; blocks pain in bigger area arm ,leg) like epidural anesthesia
(general )
AIRWAY ASSESSMENT
All patients must have an assessmet made of their airway to try
to predict those who may be difficult to intubate.
 UPPER AIRWAY:
we look for:
1. position, number, and health of teeth, identifying
any loose teeth, bridges…size of the tongue.
2. Assessing temporal mandibular joint mobility by
asking the patient to open their mouth as widely as
possible.
And Mallmpati criteria: which is classification based
on what structures you can see when the mouth is
fully opened and the tongue is protruded, and
according to the visualized structures we can give a
class to the patient.
▪ Class I: Soft palate, entire uvula, fauces, both anterior and
posterior pillars, are visible.
▪ Class II: Soft palate, entire uvula, fauces
▪ Class III: Soft palate, base of uvula visible.
▪ Class IV: Only hard palate visible
* The last two classes indicate difficult intubation.
3.Deviation of the trachea
4. Mobility of the cervical spine (flexion+extention)
5. Thyromental distance : with the head fully extended on the
neck, the distance between the mentum(bony point of the
chin)and the prominance of the thyroid cartilage (notch).
Distance less than 7 cm suggests difficult intubation.
6. others:
Wilson score:- increase in weight, decrease in head
and neck movement, jaw movment ,presence of
receding mandible or buck teeth…all suggests
difficult intubations.
Calder test:- The patient is asked to protrude the
mandible as far as possible. The lower incisors will
lie either anterior to, aligned with or posterior to
the upper incisors. The latter two suggest reduced
view at laryngoscopy.
RESPIRATORY SYSYTEM
▪ We look for signs of:
Respiratory failure (cough, SOB, wheezing)
Impaired ventilation
Collapse, consolidation, pleural effusion
Additional or absent breath sounds
▪ So we check: RR, Shape of the thoracic cage ,accessory muscles usage ,
,auscultation ,cyanosis , clubbing.
CVS
▪ We look for signs of:
Arrythmias🡺 by ECG
Heart failure🡺 edema ,SOB, palpitation, weakness
HTN
Vascular Heart disease(chest tightness or pain )
▪ So we check: HR, rhythm, BP, apical impulse for any
displacement, JVP, peripheral edema, murmurs
- Assess the anatomy for central vein cannulation
NERVOUS SYSTEM
Chronic disease of the peripheral and central
nervous systems should be identified and any
evidence
of motor or sensory impairment must be recorded.
It must be remembered that some disorders will
affect the cardiovascular and respiratory systems.
Like : head injury
INVESTIGATIONS
▪ Obtain preoperative labaratory testing only if
indicated from the preoperative history and PE.
▪ There is little evidence to support the performance
of routine investigations and this should be ordered
if the result affect the patient management.
▪ If there is No concurrent disease ,we depend on the
extent of the surgery and the age of the patient.
INVESTIGATIONS THAT USUALLY
REQUESTED:
▪ CBC: if there is significant blood loss, suspected
hematological disorders (anemia, thalassemia ,sickle
cell),recent chemotherapy.
▪ Urea and electrolytes: patients taking antihypertensive
medications, Chemotherapy(vomiting), steroids, and those
with diabetes, renal disease, adrenal and thyroid diseases ,
diarrhea.
▪ Liver function tests: known hepatic disease, a history of a
high alcohol intake (>50 units/week), metastatic disease or
evidence of malnutrition.
▪ Blood sugar: diabetics, severe peripheral arterial disease or
taking long-term steroids
▪ Electrocardiogram (ECG): patient >than 50 years old, hypertensive,
with symptoms or signs of ischaemic heart disease, a cardiac arrhythmia
or diabetics >40 years of age.
▪ Chest X-ray: symptoms or signs of cardiac or respiratory disease, or
suspected or known malignancy, where thoracic surgery is planned.
▪ Pulmonary function tests: dyspnoea on mild exertion,
chronic obstructive pulmonary disease.,COPD or asthma.
Measure peak expiratory flow rate (PEFR), forced expiratory volume in 1s
(FEV1) and FVC. (FEV1/FVC <80% COPD )
▪ Coagulation screen: anticoagulation, a history of a
bleeding or a history of liver disease or
jaundice.
▪ Cervical spine X-ray: rheumatoid arthritis, a
history of major trauma or surgery to the neck or
when difficult intubation is predicted.
▪ Urinalysis: DM, renal disease, recent UTI.
▪ Echocardiography:a useful
tool to assess left ventricular function in patients
with ischaemic or valvular heart disease, but
whose exercise ability is limited, for example by severe osteoarthritis.
2-RISK
ASSESSMNT
INTRODUCTION
Preoperative assessment is essential for the
safe use and induction of anesthesia.
Preoperative evaluation serves many
purposes, which includes:-
1. It offers the anesthetist an opportunity to
define the patient's medical and surgical
problems and plan on the usage of the proper
anesthetic technique.
2. Investigation, consultation, and treatment for
patients whose condition is not optimal.
3. To provide information and reassurance for
the patient during this stressful time.
COMPLICATIONS
AND RISK
Minor Complications Major Complications
🞆 Minor nausea 🞆 Myocardial infarction
🞆 Vomiting 🞆 Pneumonia
🞆 Readmission 🞆 Pulmonary Embolism
🞆 Urinary retention. 🞆 Renal failure/ insufficiency
🞆 Headache 🞆 Postoperative cognitive
🞆 Damage to teeth dysfunction
🞆 Sore Throat & laryngeal damage 🞆 Allergy (anaphylactic shock)

🞆 Failed IV access 🞆 Aspiration of gastric contents

•Note: 1-Minor CX are more common

than Major.
•2- These complications can lead to
morbidity\disability or even death.
•3- Therefore, to avoid any complication
screening is done.
 SCREENING

Screening helps me to Pateint that do need Thus, these patients are

categorize high risk and preoperative assessment in examined and seen at
low risk patients thus clinic: admission by the
further helping in the anesthetist.
management during 1. Who have no co-existing medical
surgery. problems
2. who require no or only baseline
investigations
3. No potential or Hx of anesthetic
difficulties
4. Require peripheral surgery
(minimal comp.)
 SCREENING
▪ Pateints with co-exisisting medical
conditions as:
1- are undiagnosed (DM, HTM)
2- Have Abnormal baseline investigations
3- Need further investigations
All are seen in the clinic expect if the
preexisting condition is well controlled thus
not requiring further evaluation. Patients who
will need to be seen by an anesthetist are
those having actual or potential anesthetic
problems as they need full assessment.
 ASSESSMENT
▪ Three components which
include:
1.the patient's medical condition
preoperatively
2.the extent of the surgical
procedure.
3. the risk from the anesthetic.
Thus classification systems are
made.
AMERICAN SOCIETY OF It is a system used to assess a patient’s
▪

ANESTHESIOLOGISTS preoperative physical condition.

PHYSICAL STATUS
CLASSIFICATION SYSTEM
CVS ASSESSMENT – NON-
CARDIAC SURGERY
▪ The leading cause of death after surgery is myocardial infarction.
Mortality from a preoperative myocardial infarction approaches
50%.
▪ Thus, Goldman Cardiac Risk Index system was used on patients
with pre-existing cardiac disease undergoing non-cardiac surgery.
 GOLDMAN CARDIAC RISK
INDEX SYSTEM

The 4 classes are:-

• class I (0–5 points) __ 1%

• class II (6–12 points) __ 5%

• class III (13–25 points) __ 16%

• class IV (=26 points) __ 56%

▪ Note: 1- >25 points – only live saving
procedures.
▪ 2- (13-25) – were advised to have
preoperative medical consultations to
lower their morbidity and mortality
 GOLDMAN CARDIAC RISK
INDEX SYSTEM
Complications predicted by previous scoring are:
▪ Myocardial Infarction
▪ Pulmonary Embolism
▪ Ventricular Fibrillation
▪ Cardiac Arrest
▪ Complete Heart Block
 REVISED CARDIAC RISK
INDEX (RCRI)
▪ Six independent variables that predict an increased risk for
cardiac complications
▪ A patient's risk for preoperative cardiac complications
increase with number of variables that are present.
REVISED CARDIAC
RISK INDEX
 RISK ASSESSMENT -
HYPERTENSION
▪ Untreated or poorly controlled hypertension may lead to exaggerated
cardiovascular responses during anaesthesia. Both hyper/hypotension
can be precipitated leading to myocardial and cerebral ischemia.
▪ Mild (SBP 140–159mmHg, DBP 90–99mmHg) No evidence that delaying
surgery for treatment affects outcome.
▪ Moderate (SBP 160–179mmHg, DBP 100–109mmHg) Consider review of
treatment. If unchanged, requires close monitoring to avoid swings
during anesthesia and surgery.
▪ Severe (SBP > 180mmHg, DBP > 109mmHg) At this level, elective
surgery should be postponed due to the significant risk of myocardial
ischemia, arrhythmias and intracerebral hemorrhage. In an emergency,
will require acute control with invasive monitoring.
 RISK ASSESSMENT -
RESPIRATORY

▪ COPD- anesthesia could lead to respiratory depression,

atelectasis, retained secretions, pneumonia and respiratory
insufficiency or failure.
▪ Obstructive Sleep apnea (altered control of breathing) – may lead
to respiratory depression. && are risk of postop. Hypoxemia.
▪ Surgery should be postponed if patient has an acute URTI only if
life threatening, because intubation leads to LRTI risk.
 RISK ASSESSMENT -
EXERCISE CAPACITY
An indication of cardiac and respiratory reserves can be obtained by
asking the patient about their ability to perform everyday physical
activities before having to stop because of symptoms of chest pain,
shortness of breath, etc.
By asking the following:
▪ Are they able to walk several blocks comfortably at a normal pace?
▪ Do they avoid stairs?
▪ If they routinely uses stairwells, how many flights are they able to
complete?
▪ Do they have to rest in the stairwell?
▪ Is this the result of fatigue, shortness of breath, or chest pain?
 RISK
ASSESSMENT -
DM
▪ Preoperative morbidity and mortality are greater in diabetic than in
non-diabetic patients.
▪ Myocardial ischemia or infarction may be clinically "silent" if the
diabetic has autonomic neuropathy.
▪ Therefore, a high index of suspicion for myocardial ischemia or
infarction should be maintained throughout the perioperative
period if unexplained hypotension, dysrhythmias, hypoxemia or
ECG changes develop
▪ Adequate control of blood glucose concentration (< 180 mg/dL)
must be established preoperatively and maintained until oral
feeding is resumed after operation.
RISK ASSESSMENT -
MEDICATIONS & ALLERGIES
▪ Metformin – shock, hypoperfusion, heart failure, and renal
failure are risk factors leading to lactic acidosis & should be
stopped few days before surgery.
▪ Beta Blockers- Decrease cardiovascular mortality
▪ Oral hypoglycemic agents are withheld
▪ If patient on long term steroids, will need stress dose steroids
to prevent Addisonian crisis.
 RISK ASSESSMENT -
ANESTHETIC HX

▪ Check the records of previous anesthetics to rule out or

clarify problems such as difficulties with intubation, allergy to
drugs given, or adverse reactions.
▪ Family hx of Malignant hyperpyrexia & Pseudocholinesterase
deficiency
 RISK ASSESSMENT –
SURGERY TYPE
▪ The type of surgery does affect risk assessment.

Types are:-
- High Risk Surgery
- Intermediate Risk surgery
- Low Risk Surgery
▪ The type of surgery the patient is undergoing will also have
its own inherent risks.
▪ The sicker the patient and the bigger the operation, the
greater the risk.
▪ ‘low risk’ doesn’t guarantee that complications will not occur
as ‘high risk’ doesn’t mean they will definitely occur.
3-PREOPERATION
PREPARATION
PREMEDICATION
INTRODUCTION
▪ Premedication is the administration of medication before anesthesia.
Premedication is used to prepare the patient for anesthesia and to help
provide optimal conditions for surgery. This includes:
▪ Reduction of anxiety and pain
▪ Promotion of amnesia
▪ Reduction of secretions
▪ Reduction of volume and pH of gastric contents (to avoid Mendelson's
syndrome)
▪ Reduction of postoperative nausea and vomiting
▪ Enhancing the hypnotic effects of general anaesthesia
▪ Reduction of vagal reflexes to intubation
▪ Specific indications, eg prevention of infective endocarditis
 ANTIEMETICS

▪ Are used either to reduce the emetic effects of anesthetic agents

(antihistamines, butyrophenones, hyoscine) or to enhance gastric
emptying (metoclopramide).
▪ Those with a risk of regurgitation of gastric contents or undergoing
procedures with a high incidence of nausea and vomiting, eg
laparoscopy, should receive agents to reduce gastric acidity.
▪ Can use H2-receptor antagonist or proton pump inhibitors several hours
preoperatively and oral sodium citrate 15-30 minutes before induction.
 4. PLAN OF
ANESTHETIC
TECHNIQUE
HOW TO DO
SO?

Having identified and evaluated our patient's problems we now ask ourselves five
questions:
1. Is the patient's condition optimal?
2. Are there any problems which require consultation or special tests?
3.Is there an alternative procedure which may be more appropriate?(for high risk
pt)
4.What are the plans for postoperative management of the patient?
5.What premedication if any is appropriate?
THANK YOU.