麻醉科 醫智庫

01. Preoperative evaluation

陳坤堡 醫師
 麻醉科 醫智庫

01-1. Goals and Benefits of

Preanesthesia Evaluation
陳坤堡 醫師
 學習大綱

1. Goals of Preanesthesia Evaluation

2. Benefits of Preanesthesia Evaluation
 Goals of preanesthesia evaluation

 Ensure patient can safely tolerate anesthesia for the

planned surgery
 Mitigate perioperative risks such as pulmonary or
cardiovascular complications
 Anesthesia preoperative evaluation
 Guiding perioperative patient management
 Reduces perioperative morbidity and enhances patient outcome
 obtain pertinent information regarding the patient’s medical
history
 formulate an assessment of the patient’s perioperative risk
 develop a plan for any requisite clinical optimization
 Preanesthesia evaluation should include
 Focused clinical examination
 Documentation of comorbid illness
 Reduction of patients’ anxiety through education
 Assure preexisting medical conditions are optimally managed
 Selective referrals to medical specialists
 Ordering of preoperative investigations
 Initiation of interventions intended to decrease risk
 Discussion of aspects of perioperative care
 Arrangements for appropriate postoperative care
 Recommendations to delay or cancel the surgical procedure
Fig. 31.1 Mechanisms by which preoperative evaluation can help influence and improve perioperative care.
 總結 Benefits of Preanesthesia Evaluation

 Reduced anxiety
 Improved acceptance of regional anesthesia
 Fewer day-of-surgery case cancellations
 Shorter hospital length-of-stay
 Lower hospital costs
 麻醉科 醫智庫

01-2. Clinical Examination

陳坤堡 醫師
 學習大綱

Medical History

Functional Capacity

Physical Examination

Airway evaluation
中國醫藥大學附設醫院 CMUH
麻 醉 前 評 估 單
Assessment of functional capacity

Metabolic equivalents (METS)

TABLE 31.1 Metabolic Equivalents* of Functional Capacity

 Physical examination (I)
 Vital signs (BP, HR, O2 saturation)
 Height, Weight
 Body mass index (BMI)
 Difficulties with airway
management
 Chronic diseases

TABLE 31.3 Classification Scheme for Body Mass Index

 Physical examination (II)
 Evaluation of heart, lungs, and skin, further focus on organ systems.
 Cardiac auscultation, inspection of arterial pulses, veins, jugular
venous distention, ascites, hepatomegaly, and peripheral edema
 Inspection of peripheral veins → assess the ease of IV access
 Auscultation for carotid bruits, especially in patients with a history of
stroke, TIAs, or head and neck irradiation.
 Examination of pulmonary system should include both auscultation
(i.e., wheezing, decreased breath sounds, abnormal breath sounds)
and inspection (i.e., cyanosis, clubbing, accessory muscle use,
respiratory effort).
Physical examination (III)…
neurologic examination (NE)
 Basic screening NE: document deficits in mental status, speech, gait,
cranial nerve function…
 For selected patients: more extensive or focused NE, document
preexisting abnormalities
 In addition, the definition of a baseline preoperative neurologic state
helps determine whether any postoperative deficits represent new
deficits versus preexisting abnormalities
 Airway Evaluation
 From anesthesiologist’s perspective, inspection of airway may be the
single most important component of PE.
 It is challenging for non-anesthesiologists to perform an adequate
assessment.
 Components of Airway Examination
 Length of upper incisors, Condition of teeth
 Relationship of maxillary incisors to mandibular incisors
 Ability to advance mandibular incisors in front of maxillary incisors
 Interincisor or intergum (if edentulous) distance (concerning if < 3 cm)
 Visibility of the uvula (concerning if Mallampati class is 3 or more)
 Shape of uvula (concerning if highly arched or very narrow)
 Presence of heavy facial hair
 Compliance of the mandibular space (concerning if it is stiff, indurated, occupied by mass, or
nonresilient)
 Thyromental distance (concerning if < 6 cm)
 Length of the neck
 Thickness or circumference of the neck
 Range of motion of the head and neck (concerning if unable to touch tip of chin to chest or cannot
extend neck)
 Mallampati score
 Status of teeth
 Degree of neck mobility (especially
extension)
 Neck circumference
 Thyromental distance
 Body habitus
 Pertinent deformities
  Age >55
 BMI > 26
 History of snoring
Difficult  Mallampati classification III or IV
Airway  Face and neck deformities
 Rheumatic Arthritis
 Cervical spine disease, or previous cervical
spine surgery
 總結
 Anesthesiologist：knowledgeable in many aspects of
internal medicine
 Clinical examination, consisting of history & PE, is a
fundamental component of preoperative evaluation
by anesthesiologists
 Helps identify underlying basis for planned surgery,
clarify extent of comorbidities, identify opportunities
for preoperative optimization, and select appropriate
preoperative testing
 Take Home message

 Comorbid medical diseases can influence anesthesia

and perioperative management
 requiring the anesthesiologist to be knowledgeable
in many aspects of internal medicine
 麻醉科 醫智庫

01-3. Preoperative Laboratory &

Diagnostic Studies
陳坤堡 醫師
 學習大綱

• pre-op. laboratory testing

• CXR
• EKG
• UA
 Preoperative Laboratory & Diagnostic Studies
 A central issue in delivering cost-effective health care to surgical
patients
 Role of pre-op. testing：screen for disease and evaluate patients’
fitness for surgery
 Routine pre-op. testing in all surgical patients (i.e., without
consideration for demographics or comorbidities) cannot be
justified.
 Routine pre-op. testing in asymptomatic healthy patients has very
poor diagnostic yield, provides little to no additional prognostic
information, and has not shown any beneficial effect on outcomes
 Preoperative Laboratory & Diagnostic Studies

 Appropriate preop. diagnostic & laboratory studies consistent with

medical history & proposed surgical procedure.
 Routine preop. testing cannot be justified because it is costly and
often clinically inappropriate.
 CBC
 Pre-op. CBC: Surgery, associated potential blood loss, &
individualized patient-level clinical indications
 Typical clinical indications: history of increased bleeding,
hematologic disorders, CKD, chronic liver disease, recent
chemotherapy or radiation treatment, corticosteroid therapy,
anticoagulant therapy, and poor nutritional status.
 NICE guidelines recommend routine CBC testing only in ASA-PS
class 3 or 4 patients undergoing intermediate grade procedures, and
all patients undergoing major procedures
 RENAL FUNCTION TESTING
 Renal function tests assess renal tubular function and glomerular filtration.
 Primary clinical indications: DM, H/T, cardiac disease, potential dehydration
(e.g., vomiting, diarrhea), anorexia, bulimia(貪食症), fluid overload states
(e.g., heart rate, ascites), known renal disease, liver disease, relevant recent
chemotherapy (e.g., cisplatin, carboplatin), and renal transplantation.
 NICE guidelines recommend routine renal function testing in ASA-PS class
3 or 4 patients undergoing intermediate procedures, and ASA-PS class 2, 3,
or 4 patients undergoing major procedures.
 If patients are deemed to be at risk for perioperative AKI, testing may also
be considered in ASA-PS class 3 or 4 patients undergoing minor procedures,
and ASA-PS class 2 patients undergoing intermediate procedures
 LIVER FUNCTION TESTING (LFT)

 Based on a history of liver injury and physical examination findings

 Primary clinical indications: history of hepatitis (viral, alcohol, drug-
induced, autoimmune), jaundice, cirrhosis, portal hypertension,
biliary disease, gallbladder disease, hepatotoxic drug exposure,
tumor involvement of the liver, and bleeding disorders.
 COAGULATION TESTING
 Routine preoperative coagulation testing is not indicated (even in
patients undergoing regional procedures) unless a known or
suspected coagulopathy is identified on preoperative evaluation.
 Primary clinical indications: known bleeding disorder, hepatic
disease, & anticoagulant use.
 2016 NICE guidelines state that coagulation testing should only be
considered in patients who are (1) ASA-PS class 3 or 4; (2)
undergoing intermediate, major, or complex surgical procedures;
and (3) known to take anticoagulant medications or have chronic
liver disease.
 URINALYSIS (UA)

 There is no indication for routine preoperative urinalysis.

 Primary clinical indications include a suspected urinary
tract infection and unexplained fever or chills.
 ELECTROCARDIOGRAM (ECG)
 Help detect a prior MI, cardiac rhythm disturbances, ischemia, chamber hypertrophy, & electrolyte
disorders
 Primary clinical indications: history of IHD, H/T, DM, heart failure, chest pain, palpitations, abnormal
valvular murmurs, peripheral edema, syncope, dizziness, dyspnea on exertion, orthopnea,
paroxysmal nocturnal dyspnea, and CVD.
 2014 ESC/ESA guidelines: patients with risk factors for IHD or suspicious symptoms, especially
undergoing intermediate risk or high-risk surgery.
 2014 ACC/AHA guidelines are fairly consistent in that they support preoperative ECGs for patients
who are undergoing intermediate-risk or high-risk surgery, and who have known IHD, significant
arrhythmia, PAD, CVD, or other significant structural heart disease.
 NICE guidelines recommend routine preoperative ECGs in ASA-PS class 3 or 4 patients undergoing
intermediate grade procedures, and ASA-PS class 2, 3, or 4 patients undergoing major procedures.
 If patients have cardiovascular disease, CKD, or DM, testing may also be considered in ASA-PS
class 2 patients undergoing intermediate procedures
 CHEST RADIOGRAPH (CXR)

 Pre-op. CXR should not be ordered routinely, but rather

selectively based on abnormalities identified by
preoperative evaluation.
 Indications: advanced COPD, bullous lung disease,
suspected pulmonary edema, suspected pneumonia,
suspected mediastinal masses, and suspicious findings
on PE (e.g., rales, tracheal deviation).
 總結

 Anesthesiologist-led pre-op. evaluation outpatient

clinic
→ Enhance OR efficiency,
decrease day-of-surgery cancellations or delays,
reduce hospital costs, &
enhance the quality of patient care.
 閱讀建議

 Yao & Artusio’s Anesthesiology：Problem-Oriented

Patient Management. 9/e
 Stoelting's Anesthesia and Co-Existing Disease 8th
Edition - August 25, 2021
 麻醉科 醫智庫

01-4. Preoperative Medication &

Risk Assessment
陳坤堡 醫師
 學習大綱

1. Preoperative Medication Management

2. Risk assessment
3. ASA-PS classification system
Preoperative Medication Management
Preoperative Medication Management
 Preoperative Risk Assessment
 A critical component of the preanesthesia evaluation is
assessment of a patient’s risk for undergoing anesthesia
and surgery.
 This assessment improves patients’ understanding of the
inherent(固有的) perioperative risks and better informs
healthcare providers’ clinical decision making.
 ASA-PS classification system
 Most commonly used method to assess overall perioperative risk is ASA-PS
classification system.
 Developed in 1941, was originally intended to facilitate collection and comparison of
statistical data in anesthesia.
 Seeks to describe a patient’s preoperative medical status, but it does not consider risks
inherent to the planned surgical procedure.
 Although not intended to guide estimation of patients’ risks for anesthesia and surgery,
the ASA-PS is often used for this purpose, especially given its simplicity of use.
 Several studies shown a correlation of ASA-PS scores with post-op. mortality and
major complications.
 An important limitation to the classification system is its inherent subjectivity;
consequently, previous research has shown only fair to modest interrater agreement
when different individuals attempt to assign an ASA-PS category to the same patient.
*The addition of “E” to the classification category indicates emergency surgery.
ASA-PS, American Society of Anesthesiologists physical status.
From Paternak LR, Johns A. Ambulatory gynaecological surgery: risk and assessment. Best Pract Res Clin Obstet Gynaecol. 2005;19:663–679.
 總結
 In addition to patients’ preoperative medical status,
which is described by the ASA-PS system
 Operative procedure is an important determinant of
perioperative risk
 Overall perioperative risk is necessarily a function of
both the risk associated with the specific operative
procedure & risk associated with a patient’s
underlying medical status.
閱讀建議
 麻醉科 醫智庫

01-5. Planning for anesthesia

陳坤堡 醫師
 學習大綱

1. PREOPERATIVE FASTING STATUS

2. PLANNING FOR POSTOPERATIVE PAIN
MANAGEMENT
 PREOPERATIVE FASTING STATUS

A. Fasting Recommendations*

Ingested Material Minimum Fasting Period

Clear liquids 2h

Breast milk 4h

Infant formula 6h

Nonhuman milk§ 6h

Light meal** 6h
Additional fasting time (e.g., 8 or more
Fried foods, fatty foods, or meat
hours) may be needed
PREOPERATIVE FASTING STATUS
實例…無痛胃鏡之麻醉

55 歲，男性，大腸癌腹膜轉移、腸沾黏，
腹脹、嘔吐>3天，抽出超過500 mL胃內容物
 PLANNING FOR POSTOPERATIVE PAIN MANAGEMENT

 A preoperative evaluation should always include baseline pain

assessment.
 Standardization of pain measurement is difficult because of the
subjective nature of the variable.
 It is therefore helpful to incorporate standardized pain
measurement scales into the preoperative evaluation process.
 The preoperative evaluation provides an
important opportunity to discuss and plan for the
management of acute postoperative pain, for
several reasons
1. adequacy of perioperative pain control is a frequent concern for
patients during preoperative evaluation.
2. intensive preoperative pain instructions may help improve
postoperative pain control in surgical patients.
3. preoperative anesthesia consultation is associated with improved
patient acceptance of perioperative regional
4. preoperative evaluation facilitates planning the perioperative care of
patients with chronic pain conditions, who often present significant
challenges with respect to managing postoperative analgesia
At a minimum, the pre-anesthesia evaluation
must include the following：
 Notation of anesthesia risk (e.g., ASA-PS classification)
 Review of the medical, anesthesia, drug, and allergy history
 Interview and examination of the patient
 Potential anesthesia problems (e.g., difficult airway,limited
intravascular access)
 Additional evaluation, if deemed necessary (e.g., stress tests,
specialist consultation)
 Development of a plan for anesthesia, including the type of
medications for induction, maintenance, and postoperative care
 Discussion of the risks and benefits of anesthesia with the patient or
the patient’s representative
 閱讀建議

 Yao & Artusio’s Anesthesiology：Problem-Oriented

Patient Management. 9/e
 Stoelting's Anesthesia and Co-Existing Disease 8th
Edition - August 25, 2021
 https://isqua.org/
 即時性評量2

An healthy 1-year-old infant is scheduled for elective

題目2 surgery. For the child, whose diet is infant formula, what is
the recommended preoperative fasting (NPO) periods?
(A) 2 hours
(B) 4 hours
選項 (C) 6 hours
(D) 8 hours
(E) 10 hours

答案 (C)
出題 Anesthesiology Self-Assessment and Board Review: Basic review, 2017, Page.
來源 404