• a complete account of all medications taken by the patient in the recent past • all pertinent drug and contact allergies • responses and reactions to previous anesthetics. • any indicated diagnostic tests, laboratory investigations, imaging procedures, or consultations from other physicians. By convention, physicians in many countries use the American Society of Anesthesiologists’ (ASA) classification to definerelative risk prior to conscious sedation and surgical anesthesia Elements of Pre Op History Patients presenting for elective surgery require a focused preoperative medical history emphasizing:
1. cardiac and pulmonary function
2. kidney disease, endocrine and metabolic diseases 3. musculoskeletal and anatomic issues relevant to airway management and regional anesthesia 4. history of responses and reactions to previous anesthetics/drugs. 5. family/personal history 6. Any coexisting illness 7. Exercise tolerance Cardiovascular issues The core goals of preoperative cardiac assessment are to : 1. determine the status of the patient's cardiac conditions 2. to provide an estimate of risk 3. to determine if further testing is warranted 4. and to determine if interventions are warranted to reduce perioperative cardiac risk.
In general, the indications for cardiovascular
investigations are the same in surgical patients as in any other patient. Pulmonary issues
Cases where there is markedly increased risk of
pulmonary complications :
• ASA Class 3 and Class 4 patients as compared to
Class 1 patients. • Cigarette smoking • Longer surgeries (>4 h) • Certain types of surgery (abdominal, thoracic, aortic aneurysm, head and neck, and emergency surgery) • General Anesthesia (compared with cases in which GA was not used) Efforts required for prevention of pulmonary complications
• focus on cessation of cigarette smoking
prior to surgery and on lung expansion techniques (eg, incentive spirometry) after surgery in patients at risk. • Patients with asthma, have a greater risk for bronchospasm during airway manipulation. • Appropriate use of analgesia and monitoring are key strategies for avoiding postoperative respiratory depression in patients with obstructive sleep apnea. Coagulation issues Three important coagulation issues that must be addressed during the preoperative evaluation: 1. How to manage patients who are taking warfarin on a long- term basis 2. how to manage patients who are taking clopidogrel and related agents 3. how to safely provide regional anesthesia to patients who either are receiving longterm anticoagulation therapy or who will receive anticoagulation perioperatively. patients deemed at high risk for thrombosis (eg, those with certain mechanical heart valve implants or with atrial fibrillation and a prior thromboembolic stroke), warfarin should be replaced by intravenous heparin or, more commonly, by intramuscular heparinoids to minimize the risk. Gastro intestinal issues
the risk of aspiration is increased in
certain groups of patients: o pregnant women in the second and third trimesters, o those whose stomachs have not emptied after a recent meal, o and those with serious gastroesophageal reflux disease (GERD). Treatment of GERD : to treat patients with consistent symptoms (multiple times per week) with medications (eg, nonparticulate antacids such as sodium citrate) and techniques (eg, tracheal intubation rather than laryngeal mask airway) as if they were at increased risk for aspiration. Element of Preoperative Physical Examination 1. measurement of vital signs (blood pressure, heart rate, respiratory rate, and temperature) 2. examination of the airway, heart, lungs, and musculoskeletal system 3. standard techniques of inspection, auscultation, palpitation are used. 4. Breath holding time should be assessed in every patient(normal value >25 seconds ; 15- 20seconds is considered borderline). 5. Proper examination of patient’s airway 6. Inspection of loose or chipped teeth, caps, bridges, or dentures. 7. Micrognathia (a short distance between the chin and the hyoid bone), prominent upper incisors, a large tongue, limited range of motion of the temporo mandibular joint or cervical spine, or a short or thick neck Preoperative Laboratory Testing 1. Chest X-ray : done as a routine practice 2. Blood glucose measurement for diabetic patient 3. Urine analysis 4. Coagulation profile for patients with suspected coagulopathy (Hb,Ht concentration) Premedication 1. Mid-azolam Adults often receive intrave- nous midazolam (2–5 mg) once an intravenous line has been established. 2. If a painful procedure (eg, regional block or a central venous line) performed while the patient remains awake, small doses of opioid (typically fentanyl) 3. Patients who will undergo airway surgery anticholinergic agent (glycopyrrolate or atropine) to reduce airway secretions DOCUMENTATION Preoperative Assessment Note Intraoperative Anesthesia Record Postoperative Notes Conclusion Preoperative evaluation is scenario which utilizes vast scales anaesthesiologists knowledge in a limited span to ensure
• Increased quality of preoperative care
• Reduced mortality and morbidity of surgery • Reduced cost of preoperative care • Reduced anxiety Terimakasih