Preoperative Assessment

Objectives:
At the end of this lecture, the student must be able to identify:
- Different phases of perioperative care.
- Goal of preoperative assessment
- Preoperative assessments.
- Preoperative Optimization.

I. Different phases of perioperative care:

What is meant by perioperative?

Perioperative is a term used to describe the entire span of surgery, including what
occurs before, during, and after the actual operation.

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II. Goals of preoperative assessment:
1. Assess the fitness for anesthesia.
2. Optimizing patient condition for anesthesia and surgery.
3. Arrange further investigations, consultations and treatments for patients not yet
optimized.
4. Allay fear and anxiety.
5. Establishment of preoperative fasting.
6. Premedication.
7. Provide appropriate information to the patient and obtain consent.

III. Preoperative assessments:

History.
Physical examination.
Preoperative investigations.

1. History:
History of present illness and reason for surgery.
Past medical history.
Medical conditions (acute and chronic).
Previous hospitalization and surgeries.
History of any past problem with anesthesia.
Allergies.
Substance use; alcohol, tobacco, street drugs.
Family history; Hereditary diseases and Anesthetic history.
Review of system.
Drug history (See below).

Take Notes!

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Drug history:

Anti-hypertensive
ACEI (Angiotensin
converting enzyme May be associated with severe hypotension during induction.
(ACE) inhibitors)
B- blocker -ve inotropic effect additive with anesthetic agents.
Ca channel blocker Decrease atrioventricular conduction and excitability.
Toxicity enhanced by hypokalemia (should be corrected) pre-
Digoxin
operatively.
Diuretics Can cause hypokalemia may potentiate muscle Relaxant
Antibiotics
Aminoglycoside Potentiate effect of neuromuscular blockers
Anticonvulsant
MAOIs React with opioid (pethidine) causing coma or convulsion
Tricyclic Anti- Inhibit metabolism of catecholamines & increase likelihood of
depressants (TCAs) arrhythmia
NSAIDS (Non-
steroidal anti-
Interfere with platelet function (coagulation mechanism)
inflammatory
drugs) & Aspirin
Anti-coagulants Bleeding with minor trauma & interfere with surgical homeostasis
Steroids Adrenocortical suppression lead to stress intolerance
Oral contraceptive
Increase risk of thromboembolism
pill
Magnesium Potentiates action of muscle relaxant.

History of smoking:
Vascular disease of peripheral, coronary, and cerebral circulation.
Lung carcinoma.
Effect of nicotine → tachycardia and hypertension.
Increase in CO hemoglobin decrease O2 delivery to the tissues.

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 Sixfold increase in postoperative respiratory morbidity.
Should be stopped 6 weeks or at least 12 hours before surgery.

2. Physical examination:
A full medical examination should be performed primary by the surgeon and
documented in the patient record.
The anesthesiologist should emphasize on cardiovascular, respiratory and airway
examination in addition to other relevant finding.

General examination:
Nutritional state.
Fluid balance.
Condition of skin and mucus membranes (anemia – perfusion – jaundice).
Temperature.

Cardiovascular examination:
Presence of dyspnea, fatigue, chest pain.
Peripheral pulse (rate, rhythm, volume).
Neck veins.
Carotid bruits.
Heart sounds.
Lower Limb edema.

Respiratory examination:
Presence of cyanosis (peripheral or central).
Presence of cough.
Presence of tachypnea.
Tracheal shift.
Auscultation of all the lung fields.

Nervous system:
Documentation of the level of consciousness
Documentation of any cranial or peripheral nerve lesions.

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Skeletal system:
Documentation of any skeletal muscles dysfunction or syndromes.

Airway examination:
Teeth exam (dentures, loose teeth, protruding upper incisors).
Prediction of difficult airway (for ventilation or endotracheal intubation)

3. Preoperative investigations:
Guided by history, clinical examination, type of surgery, age and gender of the patient.

CBC (complete blood picture):

Major surgery requiring group and screen or cross and match.
Males > 50 years.
All adult female.
Bloody surgery.
History of anemia.
Hemoglobinopathy.
CVD = Cardiovascular disorders.

Urine analysis:
Routine for all patients.

FBS (fasting blood glucose):

History of diabetes.
Patients on steroid therapy.

Renal function test (urea, creatinine, electrolytes):

All patients > 65 years.
+ve urinalysis.
Patient with renal or liver diseases.
Diabetic patients.
Malnutrition.
Dehydrated patients.
Patients on diuretics.

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 Antihypertensive.
Steroid drugs.
Pituitary or adrenal disease.
Vascular disease.
Digoxin, diuretic, or other drug therapies affecting electrolytes.

Liver function test:

History of liver disease.
Previous hepatitis.
Malnutrition.
Alcoholism.

Coagulation profile (INR, aPTT):

History of bleeding disorder.
Liver disease.
Drug abuse.
Anticoagulant therapy.

ECG:
All patients > 50 years.
Smoker > 45 years.
History of CVD and diabetes mellitus.
History of Pulmonary disease.
History of medication active on cardiovascular system or diuretics.

Chest X-ray:
All patients > 60 years.
Any possibility of cardiovascular and/or pulmonary disease.
Thyroid enlargement (thoracic inlet x-ray).

Pulmonary function test & arterial blood gases:

All COPD (chronic obstructive pulmonary disease) and asthmatic patients.
Patients scheduled for elective thoracotomy.

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Pregnancy (HCG):
Women of reproductive age.

IV. American Society of Anesthesiology Classification:

Common classification of physical status at the time of surgery.

ASA rating Description of patient

Class I (ASA 1) A normally healthy patient.
A patient with mild systemic disease e.g., controlled Type 2 DM,
Class II (ASA 2) controlled essential HTN, obesity, smoker.

A patient with severe systemic disease that is not in capacitating e.g.,

Class III (ASA 3)
stable CAD, COPD, DM, obesity.
A patient with incapacitating systemic disease that is a constant threat
Class IV (ASA 4) to life e.g., unstable CAD, renal failure, acute respiratory failure.

A moribund patient who is not expected to survive 24 h with or without

Class V (ASA 5) operation e.g., ruptured abdominal aortic aneurysm (AAA), head
trauma with increased intra-cranial pressure.

Declared brain dead, a patient whose organs are being removed for
Class E (ASA 6)
donation purposes.
For emergency operations, add the letter E after classification (e.g., ASA 3E)

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 V. Preoperative optimization:
In general, prior to elective surgery:
Any fluid and/or electrolyte imbalance should be corrected.
Extent of existing comorbidities should be understood, and these conditions should be
optimized prior to surgery.
Medications may need adjustment.

Medications:
Pay particular attention to cardiac and respiratory medications, opioids and drugs with
many side effects and interactions.

Preoperative medications to consider:

Prophylaxis:
Risk of GE reflux: sodium citrate and/or ranitidine and/or metoclopramide 30 min – 1h
prior to surgery.
Risk of infective endocarditis: antibiotics.
Risk of adrenal suppression: steroid coverage.
Anxiety: consider benzodiazepines.
COPD (chronic obstructive pulmonary diseases), asthma: bronchodilators.
Coronary artery disease risk factors: nitroglycerin and beta blockers.

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Preoperative medications to stop:
Oral anti-hyperglycemics: do not take on morning of surgery.
ACEI (Angiotensin-converting enzyme (ACE) inhibitors) and ARBs (angiotensin receptor
blockers): do not take on the day of surgery → they increase the risk of hypotension
post-induction but have not been shown to increase mortality or adverse outcomes;
therefore, some people hold and some do not).
Warfarin: (consider bridging with heparin).
ASA (acetylsalicylic acid – aspirin) and NSAIDs (nonsteroidal anti-inflammatory drugs):
in patients undergoing non-cardiac surgery, starting or continuing low-dose ASA in the
perioperative period does not appear to protect against post-operative MI or deathm,
but increases the risk of major bleeding.
Herbal supplements: stop one week prior to elective surgery.

Preoperative medications to stop:

Insulin (consider insulin/dextrose infusion or holding dose).
Prednisone.
Bronchodilators.

Diseases:
Cardiovascular and pulmonary complications continue to account for major morbidity
and mortality in patients undergoing noncardiac surgery.

Hypertension:
BP < 180/110 is not an independent risk factor for perioperative cardiovascular
complications.
Target systolic blood pressure < 180 mmHg, diastolic blood pressure < 110 mmHg.
Assess for end-organ and treat accordingly.

Coronary artery disease:

At least 60 day should elapse after a MI before a noncardiac surgery in the absence of
a coronary intervention.
This period carries an increased risk of re-infarction/death.
Mortality with perioperative MI is 20-50%.

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 Perioperative B-blockers:
▪ May decrease cardiac events and mortality (but increases risk of perioperative
strokes).
▪ Continue B-blocker if patient is routinely taking it prior to surgery.
▪ Consider initiation of B-blocker in:
- Patients with CAD or indication for B-blocker.
- Intermediate or high risk surgery, especially vascular surgery.
Risk factor assessment of non-cardiac surgical procedures:

Gradation of risk of common non-cardiac surgical procedures

- Emergent major operations, especially elderly
- Aortic and other non-carotid major vascular surgery (endovascular and
Higher
non- endovascular)
- Prolonged surgery associated with large fluid shift and/or blood loss
- Major thoracic surgery & Major abdominal surgery
- Carotid endarterectomy surgery & Head/neck surgery
Intermediate
- Orthopedic surgery
- Prostate surgery
- Eye, skin, and superficial surgery
Lower
- Endoscopic procedures

Revised cardiac risk index clinical markers:

High-risk surgical procedures Congestive heart failure

Vascular surgery
Major intraperitoneal or intrathoracic
procedures
Ischemic heart disease
History of myocardial infarction
Current angina considered to be ischemic
Requiring sublingual nitroglycerin
Positive exercise test
Left ventricular failure by physical
examination
History of paroxysmal nocturnal dyspnea
History of pulmonary edema
S3 gallop on cardiac auscultation
Bilateral rales on pulmonary auscultation
Pulmonary edema on chest x-ray
Cerebrovascular disease

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 Pathological Q-waves on ECG History of transient ischemic attack
History of PTCA and/or CABG with current
History of cerebrovascular accident
anginaconsidered to be ischemic
Diabetes mellitus Chronic renal insufficiency
Treatment with insulin Serum creatinine > 2 mg/dL

Respiratory diseases:
Smoking:
Adverse effects:
▪ Altered mucus secretion and clearance.
▪ Decreased small airway caliber.
▪ Altered oxygen carrying capacity.
▪ Increased airway reactivity.
▪ Altered immune response.
Abstain at least 8 wk pre-operatively if possible.
If unable, abstaining even 24 h pre-operatively has been shown to increase oxygen
availability to tissues.
Asthma:
Increased risk of bronchospasm from intubation.
Administration of short course (up to 1 wk) pre-operative corticosteroids and inhaled
B2- agonists decreases the risk of bronchospasm and does not increase the risk of
infection or delay wound healing.
Avoid non-selective B-blockers due to risk of bronchospasm (cardio-selective B-blockers
(metoprolol, Atenolol) do not increase risk in the short-term).
Delay elective surgery for poorly controlled asthma (increased cough or sputum
production, active wheezing).
Ideally, delay elective surgery by a minimum of 6 weeks if patient develops upper
respiratory tract infection.

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COPD:
Anesthesia, surgery (especially abdominal surgery, in particular upper abdominal
surgery) and pain predispose the patient to atelectasis, bronchospasm, pneumonia,
prolonged need for mechanical Ventilation, and respiratory failure.
Pre-operative ABG is needed for all COPD stage II and III patients to assess baseline
respiratory Acidosis and plan post-operative management of hypercapnia.
Cancel/delay elective surgery for acute exacerbation.
Predisposing risk factors for pulmonary complications:
1. Upper respiratory tract infection: cough, dyspnea.
2. Age > 60 years.
3. COPD.
4. American Society of Anesthesiologists Class 2.
5. Functionally dependent.
6. Congestive heart failure.
7. Serum albumin < 3.5 g/dL.
8. FEV1 < 2L.
9. MVV < 50% of predicted.
10. PEF < 100L or 50% predicted value.
11. PCO245 mmHg & PO250 mmHg.

Aspiration:
Increased risk of aspiration with:
Decreased level of conscious (drugs/alcohol, head injury, CNS pathology,
trauma/shock).
Delayed gastric emptying (non-fasted within 8 h, diabetes, narcotics).
Decreased sphincter competence (GERD (Gastroesophageal reflux disease), hiatus
hernia, nasogastric tube, pregnancy, obesity).
Increased abdominal pressure (pregnancy, obesity, bowel obstruction, acute abdomen).
Unprotected airway (laryngeal mask vs. endotracheal tube).

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Management:
Manage risk factors if possible.
Utilize protected airway (i.e., endotracheal tube).
Reduce gastric volume and acidity.
Delay inhibiting airway reflexes with muscular relaxants.
Employ rapid sequence induction.

Fasting guidelines:
Fasting guidelines Prior to surgery:
Before elective procedures, the minimum duration of fasting should be:
▪ 8 h after a meal that includes meat, fried or fatty foods.
▪ 6 h after a light meal (such as toast or crackers) or after ingestion of infant formula
or non-human milk.
▪ 4 h after ingestion of breast milk.
▪ 2 h after clear fluids (water, black coffee, tea, carbonated beverages, juice without
pulp).

Hematological disorders:
History of congenital or acquired conditions (sickle cell anemia, factor VIII deficiency,
ITP, liver disease).
Evaluate hemoglobin, hematocrit and coagulation proles when indicated.
Anemia:
▪ Pre -operative treatments to increase hemoglobin (PO or IV iron supplementation,
erythropoietin or pre-admission blood collection in certain populations).
Coagulopathies:
▪ Discontinue or modify anticoagulation therapies (warfarin, clopidogrel, ASA,
apixaban, dabigatran) in advance of elective surgeries.
▪ Administration of reversal agents if necessary: vitamin K, FFP, prothrombin complex
concentrate, recombinant activated factor VII.

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 Endocrine disorders:
Diabetes mellitus (DM):
Clarify type 1 VS Type 2.
Clarify treatment – oral anti-hyperglycemics and/or insulin.
Assess glucose control with history and Hba1c; well controlled diabetics have more
stable glucose levels intraoperatively.
End organ damage: be aware of damage to cardiovascular, renal, and central,
peripheral and autonomic nervous systems.
Preoperative guidelines for DM:
▪ 1. Verify target blood glucose concentration with frequent glucose monitoring:
< 180 mg/dl in critical patients, < 140 mg/dl in stable patients).
▪ 2. Use insulin therapy to maintain glycemic goals.
▪ 3. Hold biguanides, -glucosidase inhibitors, thiazolidinediones, sulfonylureas and
GLP- 1 agonists on the morning of surgery.
▪ 4. Consider cancelling nonemergency procedures if patient presents with metabolic
abnormalities (DKA, HHS, etc.) Or glucose reading above 400 mg/dl.
Hyperthyroidism and hypothyroidism:
Hyperthyroidism: can experience sudden release of thyroid hormone (thyroid storm)
if not treated or well-controlled pre-operatively.
Treatment: B-blockers and pre-operative prophylaxis.
Adrenocortical insufficiency (Addison’s, exogenous steroid use):
Consider intraoperative steroid supplementation.

Obesity and Obstructive Sleep Apnea (OSA):

Severity of OSA may be determined from sleep studies and level of pressure prescribed
for home CPAP device.
Both obesity and OSA independently increase risk of difficult ventilation, intubation
and post-operative respiratory complications.

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