Presentation by : Dr Prabhakar Moderator: Dr Deepak

Goals of Preoperative Assessment
Identification of medical conditions Initiation of further investigations Optimization of medical treatment Formulation of an anesthetic plan in terms of:
• • • • • • Regional vs. general anesthesia, or both Premedication Monitoring Intravenous access Airway management Postoperative management

Discussion of risks and gaining informed consent

Questions ?
contraindications to a laparoscopic procedure ? additional past medical or surgical information ?

additional preoperative medical or anesthesia planning ?
(planned postoperative ICU stay be required) informed consent ? standard laparoscopic approach need to be altered ? unique equipment or staffing in the operating room ?

Cardiac Assessment
• chest pain, • shortness of breath, • orthopnea, • ankle swelling, and • palpitations

Symptoms of

Perform an examination looking for evidence of cardiac disease (arrhythmias, failure, hypertension, murmurs, etc.)

. score 6 -25. cardiac mortality is 2%. cardiac mortality is 0.2%. cardiac mortality is 56%. thoracic. score >25 points. or aortic operation Age >70 yr Significant aortic stenosis Emergency operation Poor patient condition Points 11 10 7 3 5 3 4 3 Note: Score 5 or less.Goldman Risk Indices Risk factor Third heart sound or jugular venous distension Myocardial infarction in preceding 6 mo Nonsinus rhythm Abdominal.

which may last for several days after surgery. and benzodiazepines are respiratory depressant agents. . Anesthesia exerts multiple adverse effects upon the respiratory system. The induction of anesthesia produces a 20% reduction in functional residual capacity (FRC). opioids. an effect that persists postoperatively .Respiratory Assessment The preoperative respiratory assessment is aimed at quantifying respiratory function in terms of gas exchange and ability to clear secretions. Inhalational anesthetic gases.

Reduced lung volumes. and in patients with underlying lung disease. abdominal surgery has a significant effect on diaphragmatic movement. In addition. This effect is pronounced in smokers. lung function will always be worse. shallow breathing. In the immediate postoperative period.Reduced FRC encroaches on closing capacity leading to basal atelectasis. increases intrapulmonary shunting. the elderly. the obese. So patients with little respiratory reserve may require respiratory support. worsening hypoxia. and the inability to cough lead to sputum retention and set the scene for infection. . which reduces vital capacity . where pain may be severe. Atelectasis. This is particularly marked in patients having upper abdominal surgery.

such as asthma. • Symptoms should be assessed for severity by asking about exercise tolerance and degree of dyspnea. • wheeze. recent chest infections.Respiratory assessment begins with eliciting history • shortness of breath. chronic obstructive pulmonary disease. and previous hospital admissions with respiratory disease. and past symptoms of known lung disease. . • smoking. • sputum production.

Airway Assessment Airway complications are the single most important cause of anesthetic-related morbidity and mortality. neck radiotherapy.. Indicators of potential problems are . Pierre Robin syndrome. Downs syndrome. The incidence of difficult intubations is up to 5% .g. diabetes. and Treacher Collins syndrome). • • • • cervical rheumatoid arthritis. airway malignancies. and syndromes associated with difficult airways (e. previous head and neck surgery.

Bed side Screening test Interincisor Gap Calder Test Thyromental Distance Modified Mallampati Score • Five factors (obesity. reduced jaw opening. pre-sence of buck teeth. Wilson Score . to a maximum of 10 points . • A score of more than two predicts 75% of difficult intubations. or a receding mandible) are given 0 to 2 points. reduced head and neck movement.

Combining two or three tests adds incremental diagnostic value. the Modified Mallampati. and specificity of 80% to 97%. thyromental distance. respectively . and interincisor gap yield a sensitivity and specificity of up to 85% and 95%. When used together.Each test alone has a sensitivity of 20% to 62%.

• Values greater than 70% for the FEV1/FVC ratio is seen as within normal limits. Echocardiography Exercise Electrocardiogram/Stress Echo Chest Computer Tomography . and that a period of intensive care therapy may be indicated.Spirometry • Forced vital capacity (FVC). A FEV1 of less than 1 L suggests that effective coughing and clearance of sputum may be impaired postoperatively. forced expiratory volume in one second (FEV1 ). and the ratio of FEV1/FVC may be assessed.

Electrolytes. and Blood Glucose Electrocardiogram Chest X Ray Blood Gases • The peak expiratory flow rate (PEFR) is not reliable as an isolated reading. but it can provide important information on responsiveness to bronchodilator treatment in patients with asthma or chronic obstructive pulmonary disease (COPD). Values of less than 200 L/min predict a significantly reduced ability to expectorate effectively Postoperatively Peak Flow .INVESTIGATIONS Full Blood Count. • The current status may be assessed if the patient has kept a peak flow diary.

PREMEDICATION The advent of more potent. • acid aspiration prophylaxis. there is still a role aimed at targeting specific problems e. nausea and vomiting. • prevention of allergic reactions. • anxiety. • bronchospasm. However. and • as an antisialogue prior to airway manipulation. .g. less irritant anesthetic induction agents has reduced the need for premedication..

SPECIFIC MEDICAL CONDITIONS .

and patients should be delayed until blood pressure control had been achieved. the American guidelines advocate a delay in surgery while the blood pressure is treated.Hypertension In the medical setting. In patients with blood pressure in excess of this limit. In terms of a patient presenting with raised blood pressure at the time of surgery. • blood pressure should be treated prior to surgery. This is in line with the recommendations of the American Heart Association/American College of Cardiologists. surgery should proceed. hypertension is clearly related to an increase in cardiovascular events and death . . if systolic blood pressure is less than 180 mmHg and diastolic blood pressure below 110 mmHg.

. if further infarction occurs. .Recent Myocardial Infarction Traditionally. clopidogrel) increases. although risk may still be increased up to three months. the risk is increased for a longer duration and. may be permanently increased. this advice has changed and patients who have a small infarct with no other physiological change in their condition may be considered for surgery within six weeks. care must be taken in managing the needs of hemostasis for surgery and thrombosis prevention for the heart. a six-month interval between myocardial infarction and anesthesia was recommended to reduce cardiovascular risk—a plateau level that could not be substantially further reduced . As the use of antithrombotic drugs (e. In patients with a more extensive infarction. More recently.g.

and hypotension because this will result in myocardial ischemia and a downward spiral of further hypotension. The suggestion of aortic stenosis should warrant an echocardiography prior to anaesthesia. with judicious use of vasoconstrictors and incremental epidural dosing.Valvular Heart Disease Valvular heart disease may have a significant effect during anesthesia. The anesthetic technique should avoid tachycardia. vasodilation. patients may decompensate. The use of epidurals in this group of patients is controversial. As the stenosis worsens or coronary artery disease is added. . The outflow obstruction is initially compensated for by ventricular hypertrophy. However. The most important lesion from an anesthetic perspective is aortic stenosis. due to the reduction in systemic vascular resistance. safe satisfactory anesthesia may be achievable.

or a PEFR less than 50% of the predicted normal for that patient indicates moderate-tosevere asthma. FEV1 /FVC should normally be greater than 70%. Inhaled bronchodilators may need to be changed to nebulized bronchodilators during the period of admission. Resolution of recent exacerbations should be confirmed. A FEV1. An increase of greater than 15% in FEV1 bronchodilator therapy is considered clinically significant and an indication of poor control. The number of recent hospitalizations will give an indication of the severity of the patient’s condition. . Exercise tolerance should be assessed. PEFR Normal values exceed 200 L/min. Benzodiazepine and nebulized bronchodilator are udrful premedicant. FEV1 /FVC. PEFR measurement can be helpful. should be inquired about. especially the response to nonsteroidal anti-inflammatory drugs (NSAIDS). Specific triggers.Asthma Preoperative assessment should be directed at determining the recent course and control of the disease.

coughing.COPD Chronic obstructive pulmonary disease (COPD) is characterized by airflow obstruction that is generally progressive. the emphasis in assessment is on determining current status. wheezing. leading to pulmonary hypertension and right-heart failure. and sputum production should be noted. there is maldistribution of ventilation and perfusion resulting in larger areas of intrapulmonary shunting. . Hypoxemia is common. As with asthma. Many patients have some evidence of reversibility of airway obstruction. and may be accompanied by partially reversible airway hyperreactivity and increased sputum production. Recent changes in dyspnea. With advanced COPD. Enquiry should be made about recent exacerbations or respiratory tract infections and hospitalizations.

polycythemia. OHS is characterized by hypoxemia. FRC is reduced in awake obese patients. Spirometric values and. and obstructive sleep apnea with loss of carbon dioxide respiratory drive.OBESITY Marked obesity produces a restrictive pulmonary pattern. Pre-assessment should concentrate on the degree of respiratory impairment and the cardiorespiratory reserve. . vital capacity are reduced in relation to the body mass index (BMI). especially. rapidly encroaching on closing capacity. With progressive obesity. Oxygen consumption is increased and desaturation occurs rapidly in the apnoeic obese patient. and decreases significantly with general anesthesia. the Obesity Hypoventilation Syndrome (OHS) may develop. pulmonary hypertension.

the PaO 2 decreases and PaCO2 rises. Severe OSA. . Patients with OSA experience sleep fragmentation and daytime somnolence. AHI >30. Apnoea is characterized by the cessation of airflow for longer than 10 seconds. Obesity is a major risk factor for OSA. leading to arousal.Obstructive sleep apnoea is defined as more than five episodes of apnoea per hour of sleep. with pulmonary hypertension and cor pulmonale as possible consequences. During these periods of apnoea. although neck circumference greater than 42 cm correlates better with OSA than obesity itself. can result in chronic night time hypoxemia. Obstructive sleep apnea (OSA) is graded in severity by the apnoea/ hypopnoea index (AHI).

The degree of cardiac involvement should be assessed (i.e.During preassessment. Inquiry should be made about snoring. particularly should be asked about breath holding at night. Sedative premedicants should be avoided. Blood gas analysis is indicated in severe OSA to determine the patient’s baseline PaO2. . The history is of utmost importance because OSA can be diagnosed based on history alone.. a high degree of suspicion is required to diagnose OSA. Patients with severe OSA treated with nighttime CPAP should have their CPAP continued during their period of hospitalization. and to assess whether there is hypercapnia. restless sleep. right-heart failure). the patient should be referred for overnight polysomnography and continuous positive airway pressure (CPAP) initiated if appropriate. and CPAP should be available on recovery. daytime sleepiness. If suspected. and the partner.

Attempted weight loss preoperatively. Cessation of smoking. CXR.Contraindications to a laparoscopic approach: • There is no absolute contraindication to laparoscopic surgery in the obese patient. . • Cardiac and pulmonary testing as indicated in those with cardiac or pulmonary comorbidities. Additional preoperative testing/information: • • • • EKG. even if minimal.

and the patient should be counseled regarding these. • Obesity is an independent risk factor for perioperative DVT formation. • Additional ports may be required to obtain adequate exposure. and instruments may be needed. Planned alterations from the standard laparoscopic approach: • Extralong ports. • Increased chance of conversion to open laparotomy. Body weight distribution plays an important role in gaining pneumoperitoneum and selecting appropriate ports and trocars. and therefore all patients should receive prophylaxis. .Special issues for the informed consent: • Regardless of the specific procedure. laparoscopic surgery carries increased risks in obese patients. trocars.

Additional preoperative medical/anesthesia planning: • Standard risk evaluation should be performed as dictated by the patient’s age and comorbidities. • Complete muscle relaxation. . Unique OR equipment or staffing: • Increased OR time. • Special large-size OR table. • Routine medical clearance is recommended.

Patient with Previous Abdominal Surgery .

• Preoperative physical examination to appreciate the number and location of prior incisions and to look for incisional hernia(s).. . UGI for reoperative foregut surgery or CT scan for patient with diverticulitis to determine need for ureteral stenting. e. • Radiographic imaging • Standard imaging before reoperative surgery.Contraindications to a laparoscopic approach • only contraindicationis a documented history of a frozen abdomen.g. • Ultrasound of the abdominal wall may help map adhesions preoperatively. Additional preoperative testing/and pertinent past surgical history: • Previous operative records • Note the amount and type of adhesions encountered at the previous surgery.

• Increased risk of enterotomy or other visceral injury. • Additional ports may be required for adhesiolysis. .Special issues for the informed consent: Unique OR equipment or staffing: • Increased chance that conversion to an open laparotomy will be necessary. • Increased OR time. • Open instruments may be needed in case of conversion.

Pregnant Patient .

cholecystitis. torsion of the ovary. or a number of other problems that may require urgent or emergent surgery. .The pregnant patient may develop appendicitis. The height of the gravid uterus can alter the position of the intestine and other intraabdominal organs and may necessitate a different port arrangement. The surgeon must determine the status of the pregnancy and inform the patient of both the routine risks and the pregnancy related risks of surgery.

which can induce preterm labor. It is important to avoid manipulation of the uterus during surgery.Contraindications to a laparoscopic approach: Most authorities recommend avoidance of pneumoperitoneum and laparoscopy until the second trimester for indicated nonemergent operations. In the second and third trimesters. . because of the size of the gravid uterus. the location of the intestine and other viscera shifts in a cephalad direction.

• Consider arterial blood gas monitoring. An obstetrician should evaluate all pregnant patients perioperatively. b. • Keep end-tidal CO2 between 25 and 33 by changing minute ventilation. c. Special anesthetic precautions should be used to avoid aspiration and hypotension.Additional preoperative medical/anesthesia planning: a. Avoid fetal acidosis. .

Special issues for the informed consent: • Increased chance of conversion to open laparotomy. • The risks relating to surgery during the first trimester include teratogenesis and a miscarriage rate of approximately 12%. ports. • The possibility of damaging the gravid uterus with laparoscopic instruments. up to 30% of known pregnancies undergo spontaneous abortion. • The risks of surgery during the third trimester includes a risk of preterm labor and premature delivery. Patients should be informed of the following: . • The risks of surgery during the second trimester include a 5%–8% risk of preterm labor. • Before 14 weeks. or trocars. in the absence of surgery. This is an important point that should be documented in the preoperative consent.

the pneumoperitoneum should be released and the patient hyperventilated to expel the CO gas before continuing the procedure.Planned alterations from the standard laparoscopic approach: Minimize operative time so that fetal acidosis is minimized. Solicit the most senior assistant available even for a “minor” case. Maternal monitoring with end-tidal CO2 ± arterial blood gas monitioring Fetal acidosis is known to occur with CO2 pneumoperitoneum. although the short. It is important to note that the fetus is usually more acidemic than the mother. Use a lead shield to protect the fetus during cholangiography. Should the mother become acidemic. Pre and postoperative fetal heart tones should be obtained and carefully documented when surgery is performed during the second And third trimesters.and long-term effects of this are unknown. Minimize pneumoperitoneum pressures to the 10–12 mmHg level. The risk of thromboembolism is increased during pregnancy. . Routine use of pneumatic compression devises.

Patients with Significant Cardiopulmonary Comorbidity .

The CO2 gas used for the pneumoperitoneum raises the intraabdominal pressure from 0 to 15 mmHg. a hypercarbic acidemic state results. even for minor procedures. . resulting in hemodynamic and pulmonary function alterations. the patient with significant cardiopulmonary disease may not have the physiologic reserve to appropriately compensate. these patients need very close monitoring during laparoscopic surgery. The healthy patient is able to compensate for these changes. however. Due to the transperitoneal absorption of the insufflated CO2 gas into the blood.An important difference between open and laparoscopic surgery are the CO2 pneumoperitoneum-related intraoperative physiologic effects. thus. These minor physiologic stressors can have major implications in highrisk cardiopulmonary patients.

.Contraindications to a laparoscopic approach: There are no absolute contraindications to a laparoscopic approach in a patient with significant cardiopulmonary disease.

death).Clinical predictors of increased perioperative cardiovascular risk (myocardial infarction. Major risk Unstable coronary syndromes —Recent MI —Unstable or severe angina —Decompensated CHF Intermediate risk Mild angina pectoris (class I and II) Prior myocardial infarction by history or pathologic Q waves Diabetes mellitus Compensated or prior CHF Minor risk Advanced age Abnormal ECG Rhythm other than sinus Low functional residual capacity History of stroke Significant arrhythmia —High-grade AV block —Symptomatic ventricular arrhythmia in the presence of underlying heart disease —SVT uncontrolled rate Severe valvular disease . congestive heart failure.

echo stress.) • Holter monitor or other arrhythmia evaluation • Digoxin levels • Pulmonary function testing • Carotid duplex . etc.Additional preoperative testing/information: Mandatory • EKG • Hematocrit • Electrolytes • Chest radiograph May be indicated (depending on the patient’s history and situation) • Echocardiography • Stress test (standard treadmill. thallium.

• Arterial line for hemodynamic and acid-base monitoring All patients with significant cardiopulmonary disease should have an arterial line during laparoscopic surgery. • Furthermore. Patients with pulmonary disease are less able to effectively eliminate CO2 and are thus more susceptible to acidemia with its harmful physiologic implications. . These should be initiated in consultation with the anesthesiologist. b. the end-tidal CO2 is not an accurate reflection of the arterial PCO2.Additional preoperative medical/anesthesia planning: a. Schedule a postoperative ICU bed. Medical clearance. • Strongly consider central monitoring. The end-tidal CO2 lags behind the arterial PCO2 . d. Pulmonary function testing and room air arterial blood gas analysis. Anesthesia considerations. • This line is crucial for accurate hemodynamic monitoring in the face of increased afterload and decreased preload imposed by the pneumoperitoneum. c. Patients with diminished ejection fraction may benefit from central monitoring of cardiac filling by the anesthetist (Swan-Ganz catheter).

Planned alterations from the standard laparoscopic approach: Use lower pressures for pneumoperitoneum (10–12 mmHg). preload. For patients with congestive heart failure it is crucial to avoid overresuscitation. . This is not a linear relationship. Pulmonary and hemodynamic changes are related to the pneumoperitoneum pressure. patients on chronic diuretic therapy) are more prone to developing significant cardiovascular alterations as a result of CO2 pneumoperitoneum. especially those patients who have undergone a bowel preparation. At low pressures (0–10 mmHg). even at low pressures. Patients who are volume depleted (e.. These issues should be discussed with the anesthetist. it is important to adequately hydrate patients preoperatively. relatively few changes can be detected in a normovolemic healthy adult.g. Therefore. and cardiac function are affected. afterload. This relationship begins to change rapidly as intraabdominal pressure increases. At moderate pressures (10–22 mmHg).

then special equipment (dedicated insufflators. If helium or nitrous oxide gas is to be used to establish and maintain pneumoperitoneum. there is a theoretical risk of gas embolism.) is usually required. b. Helium or nitrous oxide gas pneumoperitoneum. • If available for the pneumoperitoneum can minimize the effects of hypercarbia and acidemia. • Further. the hemodynamic alterations related to the elevated intraabdominal pressure remain the same.Unique OR equipment or staffing: a. . Minimize OR time by soliciting the most senior assistant available. • However. etc.

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