Pre-Anesthetic care and

patients optimization

Presenter: Dr. Mwasapi P. P.

Facilitator: Dr. Mbanga

1
 layout
• Introduction
• Goals
• Steps of Preoperative Evaluation
• Airway Assessment
• Systemic assessment
• Recommended lab tests
• Influence of prescribed drugs on current anesthesia
• Optimization
• References.
2
 Introduction

• Preoperative evaluation consists of gathering information on the patient and

formulating an anesthetic plan for reduction of perioperative morbidity and
mortality

• A procedure to ensure that patient is asymptomatic from the anesthetic risk point
of view before surgery by physiological and psychological preparation.

• Surgeries may be classified into:

– Type A- Minimally invasive
Little physiological changes e.g. cataract

– Type B- Moderately invasive

Modest physiological changes e.g. TURP

– Type C- Highly invasive

Significant physiological disruption e.g. THR
3
4
 Goals of pre-anesthetic evaluation

• This has been especially important in patients with multiple

medical risks and comorbid conditions:
– Example: DM, HTN, THYROIDISM, RENAL FAILURE, LIVER FAILURE.

• The anaesthesiologist
– is uniquely qualified to assess risk
– is responsible for deciding fitness for anaesthesia
– must see all patients before operation

• The aim of assessment is to improve outcome

• Blanket pre-op investigations waste resources & time

5
 Goals..
• Screen for and manage co-morbid disease
• To assess and minimise risks of anaesthesia
• To identify need for specialised techniques
• To identify need for advanced post-op care
• To educate about anaesthesia
• To obtain informed consent
• To avoid unnecessary delays/cancellations
• To motivate patients to improve pre-op

6
 Goals..
• A change in the procedure and manner of preoperative evaluation
requires the anesthesiologist to achieve a high level of efficiency &
accuracy in assessment of the patient's
– history,
– physical examination,
– differential diagnosis,
– and planning of management.

• Both The Joint Commission (TJC) and the American Society of

Anesthesiologists (ASA) have developed standards and
requirements for preoperative anesthesia evaluation.

• Recent & updated preoperative evaluation guidelines published by

multiple medical specialties have led to protocols for evaluation in
preparing patients for anesthesia and surgery.
7
8
 Preoperative Risk Assessment

• The current ASA risk classification system attempts

to give a subjective and relative risk based only on
the patient's preoperative medical history (i.e., no
consideration of diagnostic studies).

• ASA Minimum Pre-op Visit Components

– Medical, anaesthesia and medication history
– Appropriate physical examination
– Review of diagnostic data (ECG, labs, x-rays)
– Assignment of ASA physical status
– Formulation and discussion of anesthesia plan
9
 The ASA Physical Status Classification
Mortality
ASA 1 Normal healthy patient 0.1%
ASA 2 Mild systemic disease( mild asthma or controlled HTN) - 0.2%
no impact on daily life. Unlikely to have an impact on
anesthesia and surgery

ASA 3 Severe systemic disease (renal dialysis, classII CHF) - 1.8%

significant impact on daily life. . Probable impact on
anesthesia and surgery

ASA 4 Severe systemic disease that is a constant threat to life, 7.8%

(acute MI, Rs Failure that needs mechanical ventilation)
Major impact on anesthesia and surgery

ASA 5 Moribund, not expected to survive with or without the 9.4%

operation

ASA 6 Declared brain-dead patient - organ donor

E Emergency surgery 10
Components of the Preoperative Medical History

• Particulars
• HPI
• ROS
• PMHX
• Drug allergies
• FSHx
• PE
• Lab investigations
• Anesthetic plan
 Particulars
• Patients name
• Age
• Sex
• Date of surgery
• Planned surgery
• Surgeon
• Primary care
• Other doctors number
12
 History
• Medical problems (current & past)
• Previous anaesthesia & related problems
• Family anaesthesia history
• Allergies and drug intolerances
• Medications, alcohol & tobacco
• Review of systems (include snoring and fatigue)
• Exercise tolerance and physical activity level

13
Components of the Preoperative Medical History

1. List all the operation by dates:

2. List all the allergies to medicines and latex &

your reaction to them

3. List all the medication you have taken last

month including over the counter ,inhailers
herbs ects.(if possible by name and dosage if
remember)
14
 HPI

• Evaluation for anesthesia starts with

– Reason that the patient is having surgery
– How the surgical condition developed and any previous
therapies related to this problem

• Equally important in identifying & establish disease

severity, current or recent exacerbations, the stability, and
previous treatment of the condition or planned
interventions.

• The extent, degree of control & activity-limiting nature of

the problems are equally important. 15
 ROS

• A general examination of all organ systems needs to

be performed.
• E.g asking patients whether they have ever had
problems with their
– Airway : The presence of any two of the following ↑ the
chance that a patient has sleep apnea:
• Snoring, Daytime sleepiness, Hypertension ,Obesity. Questioning
the patient about snoring and daytime somnolence may suggest
undiagnosed sleep apnea, which has implications for anesthesia.

– Lungs (RS):Difficult in breathing,cough, sputum, smoking,

asthma, breathlessness and exercise tolerance. History of
previous chest disease (TB, bronchitis etc)
16
 RO S..

• Heart (CVS)
– orthopnea,
– Shortness of breaths,
– Exercise tolerance

• Kidneys & GUS - dysuria

• nervous system (CNS) - convulsions
• GIT - constipations
• MSS – tremors, Mysthenia gravis, etc
• whether they have had cancer, anemia, or bleeding problems
• Finally, a review of records from primary care physicians,
specialists, or the hospital can reveal issues that the patient may
not recall.
17
 PMHx

ANAESTHETIC HISTORY

• Any problems encountered during past anaesthetics must be

fully investigated.

• Records of previous occasions yield a wealth of information on

response to various drugs, intubation difficulties, allergic
responses and post–operative problems.

• Family anaesthetic history is also important because certain

abnormal and possibly dangerous responses to drugs (e.g.
malignant hyperpyrexia, suxamethonium apnoea) tend to run
in families.
18
 PMHx..

• Further, several diseases which can give rise to "anaesthetic

problems" for instance sickle cell disease, blood dyscrasias,
have a familial incidence.

• Prescription &over-the-counter medications and herbals,

should be carefully recorded, along with dosages and
schedules.

• Recent but currently interrupted medications should be

included.

• Inquire about allergies to drugs and substances such as latex.

19
 PMHx..

• Hx of Malignant hyperthermia (MH) or a suggestion of it

(hyperthermia or rigidity during anesthesia) in either a
patient or family member

• Family history of pseudocholinesterase deficiency should be

identified preoperatively.

• A significant history of heartburn & associated reflux or after

a period of fasting comparable to what will occur
preoperatively, is important.

• Women of childbearing age need to be prompted to recall

their LNMP & their likelihood of being pregnant.
20
 PMHx..

• Past surgical procedures as well as that for

which the patient is being assessed are
important.

• Some operations, such as those on the heart,

lungs, kidneys and CNS may tend to interfere
with vital functions under anaesthesia.

21
 FSHx

• Use of tobacco, alcohol, or illicit drugs should be documented.

• Quantitatively documenting tobacco- number of packs of

cigarettes smoked per day times the number of years of smoking)
is best.

• Smoking increases intra and post-operative morbidity due to

associated bronchial exudation and bronchospasm.
• It should ideally be given up three days pre-operatively.
• However, cessation for even 24 hours pre-operatively reduces the
morbidity. respiratory or airway complications (including oxygen
desaturation), and severe coughing.
 
22
 Physical Examination
• Minimum requirements
– Airway assessment
– Heart & lungs
– Vital signs including O2 saturation
– Height & weight (BMI)

23
 Airway Examination
• Mallampati score
• Upper lip bite test (Teeth and bite) Ability to protrude
lower incisors beyond upper
• Inter-incisor distance (Mouth opening)
• Thyro-mental distance > 6.5cm
• Sterno-mental distance > 12.5cm
• Cormark and Lehane score
• Length & thickness of neck
• Range of motion of head & neck
• Facial hair

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 Mallampati classification

• Class I = visualize the soft palate,

uvula, anterior and posterior pillars.

• Class II = visualize the soft palate and

uvula. • Upright,
• maximal jaw opening,
• Class III = visualize the soft palate
and the base of the uvula. • tongue protrusion
without phonation
• Class IV = soft palate is not visible at
all.
 ULBT (Teeth and Bite)

• Class 1:
Lower incisors can bite upper lip
above vermillion line.

• Class 2:
Lower incisors can bite upper lip
below vermillion line.

• Class 3:
Lower incisors cannot bite the upper lip upper lip.

26
 Inter-incisor distance

 Less than or equal to 4.5

cm is considered a
potentially difficult
intubation.

 Generally greater than

2.5 to 3 fingerbreadths
(depending on
observers fingers)
 Thyro-mental distance (TMD)

• Upright
• Full neck extension
• Mouth closed
• Distance from upper
boarder of thyroid
cartilage (laryngeal
prominence), to the boney
point of the mentum.
• Distance < 6.5cm may be
difficult intubation
 Sterno-mental Distance (SMD)

• Extended head and

neck,

• mouth closed,

• distance <12.5cm is a
difficult intubation
 CRANIOFACIAL DEFORMITIES

Treacher Collins Pierre Robin Goldenhar's

30
Why would this man’s airway
be difficult to manage?
31
 Independent Predictors of Difficult Mask Ventilation and Intubation
Difficult Mask Ventilation P-value
Beard 0.0001
History of snoring 0.001
BMI > 30 0.0001
Mallampati III or IV 0.001
Age > 50 0.01
Severely limited jaw protrusion 0.03
Difficult Mask Ventilation & Intubation
Severely limited jaw protrusion 0.0001
Thick neck/mass 0.02
History of sleep apnoea 0.04
BMI > 30 0.05
History of snoring 0.05

32
 Physical Examination - Risk Factors for Difficult Intubation
Risk Factor Detail Level of Risk
Weight < 90 kg 0
90-110 kg 1
> 110 kg 2
Head & Neck Movement > 90 o 0
Approx 90 o 1
< 90 o 2
Jaw movement IG > 5 cm or Slux > 0 0
IG = Interincisor gap IG < 5 cm or Slux = 0 1
Slux = mandibular subluxation
IG < 5 cm or Slux < 0 2
Receding Mandible Normal 0
Moderate 1
Severe 2
Protruding maxillary teeth Normal 0
Moderate 1
Severe 2
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Cormack & Lehane Score
1 2

3 4

34
CVS evaluation for non-cardiac surgery

35
 Evaluating Cardiac Disease
• Arrhythmia / Abnormal ECG
• Heart failure
• Ischaemic heart disease
• Undiagnosed murmur
• Pacemaker or IACD

36
 Arrhythmias/ECG abnormalities
• Further work-up or therapy needed
– New onset AF
– Symptomatic bradycardia
– High-grade heart block (2nd or 3rd degree)
– Uncontrolled AF
– VT
– Prolonged QT
– New LBBB
– RBBB with right precordial ST elevation (Brugada)
37
 Pacemakers/IACD
• Determine type
• Determine features
• Pacemaker check/interrogation pre-op
• Disable rate-adaptive mechanisms
• Disable anti-tachyarrhythmia functions
• Magnet not recommended for modern devices

38
 HF - NYHA Functional Class
Class I No limitation of physical activity; ordinary activity does not cause fatigue,
palpitations or syncope

Class II Slight limitation of physical activity; ordinary activity results in fatigue,

palpitations or syncope

Class III Marked limitation of physical activity; less than ordinary activity results in
fatigue, palpitations or syncope; comfortable at rest

Class IV Inability to do any physical activity without discomfort; symptoms at rest

39
 Pulmonary Hypertension
• High risk
• ECG & echo
• Disease severity indicators
• SOB at rest
• Metabolic acidosis
• Hypoxaemia
• Right heart failure
• Syncope

40
 Evaluating Respiratory Disease

• Mild symptoms - can usually proceed

– huge inconvenience to patient if cancelled
• Intermediate severity - ?
– risk of increased bronchial reactivity
• Severe symptoms or underlying disease
– postpone

41
 Sleep-disordered Breathing
• 24% of middle aged men (< 15% diagnosed!)
• OSA - complete obstruction for 10s +
• OH (obstructive hypopnoea) > 4% drop in sats
• CVS disease common
• Berlin Questionnaire
• Snoring
• Daytime sleepiness
2 or more = high
• Hypertension
risk for OSA
• Obesity

42
 Evaluating Respiratory Disease..
Established Risk Factors for Pulmonary Complications
Urea > 10.7 mmol/L (30 mg/dL) [OR 2.29]
Partially or fully dependent [OR 1.92]
Age > 70 [OR 1.91]
COPD [OR 1.81]
Neck, thoracic, upper abdominal, aortic or neurological surgery
Prolonged procedures (> 2 hours)
Emergency surgery [OR 3.12]
Hypoalbuminaemia (< 30 g/L) [OR 2.53]
Exercise tolerance < 1 flight of stairs / 100 yards
BMI > 30

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 Laboratory Tests

• Based on history or physical examination

• Disadvantage
1. Increased cost
2. Delay in surgery
3. Medico legal problem

• Advantage
1. Surgeon comfortable
2. Anaesthesiologist comfortable
 Recommended test Guidelines For
Asymptomatic Patient

• Age up to 49 yrs CBC

• Age 50-64yrs CBC,ECG

• Age > 65 yrs CBC, ECG, CXR

Urine analysis
BUN/ Cr, Electrolyte
Blood Sugar

• Type C Surg Blood Gr , ALB, Plt

45
Disease based identification Tests
Alcohol abuse CBC, PT/PTT, AST/Alkp, ECG, Plt
Adrenal cortical Disease CBC, Elec, Glu, Plt

Anemia CBC, Plt

Cancer, except skin, without known CBC, CXR, Plt

metastases

Diabetes Elec, BUN/Cr, Glu, ECG

Hematologic abnormalities CBC, T/S &AB, PT/PTT, Plt

Exposure to hepatitis AST/Alkp, BUN/Cr

Hepatic disease PT/PTT, BUN/Cr, AST/Alkp

Malignancy with chemotherapy CBC, PT/PTT, BUN/Cr, AST/Alkp, CXR, Plt

Malnutrition CBC, T/S &AB, PT/PTT, Plt

Morbid obesity BUN/Cr, Glu, ECG

Peripheral vascular disease or stroke CBC, Glu, BUN/Cr, ELEC, Plt

46
Disease based identification tests

Personal or family history of CBC, PT/PTT, Plt

bleeding
Poor exercise tolerance or “real CBC, BUN/Cr, Glu, Plt
age” over 60
Possibly pregnant HCG, P/US
Pulmonary disease CBC, Elec, BUN/Cr , Glu, Plt
Renal disease CBC, Elec , BUN/Cr, Plt
Rheumatoid arthiritis CBC, ECG, CXR+, Plt

Sleep apena CBC, ECG, Plt

Smoking>40 pk/yr CBC, ECG, CXR+, Plt

Suspected UTI r prosthesis insertion UA

Systematic lupus BUN/Cr, ECG, CXR+

47
Therapy based indications TESTS

Radiation therapy CBC, ECG, CXR, Plt

Use of anticoagulants CBC, PT/PTT, Plt

Use of digoxin and diurectics Elec, Bun/Cr, ECG

Use of statins AST/Alkp, ECG

Use of steroid Eelc, Bun/ Cr, Glu

Procedure based indications

Procedure with significant blood loss CBC, T/S & ALB, Plt

Procedure with radiographic dye Bun/Cr

Class C Procedure CBC, T/S & ALB, Elec, Bun/Cr, Plt

48
Before the patient leaves the ward a senior nurse
should:
– Check the identity of the patient
– Check the site and side of the operation
– Ensure the consent form is signed in accordance with the rules of
the hospital
– It is good to weigh every patient At least every child under the age
of 12 must be weighed to allow calculation of drug dosages
– Grossly underweight and overweight adults must also be weighed
– Ensure that fasting rules have been observed
– Remove lipstick, nail varnish, etc.
– Remove dentures, artificial limbs and artificial eyes
– Empty bladder
– Dress the patient in a linen gown with an identification label
– Give premedication if any
49
Influence of drugs previously or currently taken
in current anesthesia
• Steroids
– Prolonged steroid therapy (> 10mg
prednisolone/day) results in atrophy of the
adrenal glands
– Collapse, with a fall of blood pressure, may
ensue.
– Many different regimes have been described to
provide perioperative steroid cover.
– Hydrocortisone (rapidly acting) is the drug most
frequently used – administered at induction

50
 St ero ids ..

• Steroid cover is provided if the patient has had steroids in

the three months before surgery unless the surgery is very
minor and imposes very little stress on the patient

• Any unexplained fall in blood pressure either during or after

surgery is treated with steroids.

• However hypotension from more common causes i.e. blood

loss or hypoxia must be excluded.

• The steroid cover is maintained until the stress of the

operative and post-operative period is over and then
gradually reduced.
51
 Antihypertensive drugs

• Drugs produce their effect by a ↓ in peripheral vascular

tone.
• This interfere with circulatory homeostasis under
anaesthesia.
• Most patients are left on these tablets until the day of
operation.
• The anaesthetist must bear in mind that these patients
cannot compensate for such stresses in the same way as
normal patients can, as:
– blood loss,
– changes in posture,
– intermittent positive pressure ventilation (IPPV), etc.
– Furthermore, they may react badly to drugs such as thiopentone
which can cause a fall in blood pressure. 52
 Antihypertensive drugs..
• Beta blockers
– Used for the treatment of
• hypertension,
• cardiac arrhythmias,
• ischaemic heart disease, etc
– In most cases the patients may remain on these drugs but
remember that they cannot compensate efficiently, in the face
of cardiovascular stress.

• Diuretics
– Prolonged diuretic therapy interferes with electrolyte balance.
– This must be checked pre-operatively (especially potassium)
– Hold on diuretics unless thiazides for HTN or severe HF
53
 Other drugs..
Insulin
• Patients on antidiabetic treatment must be carefully assessed by the
anaesthetist for pre and post-operative care

Antibiotics
• Large parenteral doses of antibiotics – neomycin, streptomycin and others –
have been known to potentiate the action of non-depolarising relaxants.

Phenothiazines
• These cause peripheral vasodilatation and result in a fall in blood pressure
under anaesthesia. They also potentiate the action of narcotics and
barbiturates and these drugs must be used in smaller doses.

 
54
 Monoamine oxidase inhibitors (MAOI)
• The actions of these drugs are imperfectly understood.
• They interact with narcotic analgesics,
– e.g. pethidine and morphine and result in various bizarre reactions
• severe hypo or hypertension,
• coma,
• convulsions,
• Cheyne Stokes respiration and death.
• They also react abnormally with pressor drugs and potentiate the
side effects of barbiturates.
• The effects of MAOI last from 1 to 2 weeks depending on the
drugs. Suspension of MAOI will be necessary for major surgery
requiring post-operative analgesia.
• This must be done 10 to 14 days pre-operatively.

55
 Periop Medication Management

• What to stop (suggestions! - discuss with cons)

• What to keep
• What else to give

• Hold on day of surgery

– Insulin & OHA - see hospital diabetic protocol
– Vitamins & iron
– ACEI’s or ARB’s (individual choice)
• depends on procedure/risk of hypotension
– Hold sildenafil/tadalafil from night before
56
 Preop Medicines Management
Stop 48 hours pre-op
NSAIDs
Stop 4 days pre-op
Warfarin (convert to enoxaparin)
Stop 7 days pre-op
Clopidogrel
Aspirin 75 mg usually continued (check with consultant)
Herbal remedies
HRT

57
 Premedication
• Alleviate anxiety/sedation/amnesia
• e.g. temazepam 10-20 mg, midazolam pre-induction
• Reduce risk of reflux
• e.g. ranitidine/lansoprazole/citrate/metoclopramide
• Manage pain
• e.g. paracetamol, gabapentin, topical LA
• Control perioperative risk
• e.g. b blockade, a-2 agonists
• Dry secretions
• e.g. Glycopyrollate, atropine
• Decrease anaesthetic requirements
• e.g. clonidine

58
 Anti acids

• Sodium citrate (a non-particulate antacid) can be used pre-operatively to

counteract the acidity of the gastric contents.
– It takes approx. 10 minutes to work and its effects last approx. 20 minutes.

• H2 blockers i.e. ranitidine given at least 1 hour prior to surgery may also
↓the acidity of gastric contents.
– Metoclopramide given at the same time may benefit.

• Omeprazole given 2–6 hours prior to surgery also helps reduce gastric
acid.

• Regional techniques may be the safest.

• Special rapid sequence induction techniques should be used in general

anaesthesia unless an awake intubation is indicated. 59
 Fasting Guidelines
• The period of fasting will depend on the urgency of the
procedure.

• All emergency patients should be treated as potentially at

risk of aspiration and anaesthetised using a rapid sequence
induction.

• Gastric emptying is delayed in the following situations:

patients in labour, with head injuries or severe trauma and
patients receiving drugs eg opiates.

• very ill patients have a delayed gastric emptying time.

60
Fasting Guidelines..

61
 Optimization

• A. Respiratory disorders

1. Asthma
– must be treated with the appropriate bronchodilators until
the chest is clear for auscultation, before elective surgery is
contemplated.
– Patients with asthma are quite good at estimating their
current status and breathing capacity when asked about
what percentage they are presently at (100% being normal).
– Patients taking oral steroids need blood glucose checked
and may require perioperative steroid supplementation.

62
 Optimization..

2. Chronic Obstructive Pulmonary Disease

– Includes chronic bronchitis and emphysema
– Due to exposure to pollutants such as cigarette smoke
or substances in the environment (air pollution,
allergens, grain, dust, and coal), α1-antitrypsin
deficiency, chronic infections, and long-standing
asthma.
– Dyspnea, coughing, wheezing, and sputum production
are common features.
– PFTs have not been shown to predict perioperative
outcome.
63
 Optimization..

3. Restrictive Pulmonary Disorders

– Distinguished by a ↓ in total lung capacity
– Pulmonary conditions include idiopathic interstitial
pneumonia, interstitial lung disease related to connective
tissue disease, lung resection, and pulmonary fibrosis.
– Extrapulmonary disorders are caused by chest wall
limitations (kyphoscoliosis, obesity, ankylosing
spondylitis), muscle dysfunction (muscular dystrophies,
myasthenia gravis, paralyzed diaphragm), or pleural
disease (mesothelioma, effusion, pneumothorax).
– Hx of associated diseases or symptoms prompts the
directed evaluation.
64
 O pti miz ati on..

• Restrictive Pulmonary Disorders..

– A CXR and PFTs are indicated to establish a diagnosis or evaluate
acute or progressive worsening but are not routinely necessary
preoperatively.
– FEV1 and FVC are ↓ proportionally, so the ratio is normal.

– Are at risk for pulmonary hypertension, which may not be

diagnosed or communicated to caregivers because of overlapping
symptoms with restrictive lung disease.

• Patients Scheduled for Lung Resection

– Most have underlying lung disease,
– PFTs may be useful in predicting risk or excluding patients who
may not have adequate pulmonary reserve after resection
65
 Optimization..
• B. Anaemia
– must always be investigated before treatment

– Ideally major surgery should not be performed if the

patient's Hb is <10 g/dl but this is not always possible and a
minimum of 8g /dl can be accepted.

– The urgency and cause of the anaemia e.g. menorrhagia,

may have to be taken into account.

– Proposed surgery would necessitate blood transfusion then

the patient's blood must be grouped and cross–matched.
66
 Optimization..
•C. Cardiovascular Disease (ECG , ECHO , stress ECG)

1. Myocardial infarction:

–A minimum of three months and preferably six months, must be allowed before
elective surgery.

–Patients with ischemic heart disease require CBC, and transfusion for
anemia should be considered.

–In brief, patients taking statins and β-blockers should continue without
interruption throughout the perioperative period.

–Consideration to continuing aspirin perioperatively or discontinuing for the

shortest duration possible if used for secondary prevention of vascular
events 67
 2. Cardiac failure

• Must be treated before elective surgery.

• Chronic inflammatory conditions (e.g., RA, SLE), chronic

steroid use, and chest irradiation increase the risk for CAD
but have not been shown to be significant predictors of
perioperative cardiac complications.

• LVH independently increases the risk for perioperative

cardiac morbidity.

• Presence of HF or dyspnea of unknown origin, ECHO

provides information that will modify management.
68
 Cardiac failure..

• Medical therapy:
–β-blockers, hydralazine, nitrates, and digoxin, needs to be
optimized and continued preoperatively.
–ACEIs, angiotensin receptor blockers (ARBs)
–diuretics (including spironolactone), and anticoagulants, even
on the day of surgery.
–Selectively continuing or discontinuing these drugs depends on
the volume and hemodynamic status of the patient, the degree
of cardiac dysfunction, and the anticipated surgery and volume
challenges.
–Continuing all medications for patients with severe dysfunction
who are scheduled for minor procedures is probably best.
 3. Hypertension
•Must be treated pre-operatively. Uncontrolled hypertension can result in
LVF, Arrhythmias and Cerebrovascular disturbances under anaesthesia

•Paroxysmal HTN or HTN in young individuals should prompt a search for

causes such as Coarctation, Hyperthyroidism, Pheochromocytoma, or
even illicit drug use such as cocaine Amphetamines, or Anabolic steroids.

• Ideally the blood pressure should be stabilised to a diastolic pressure of 90–

100mmHg.

• It is probably safe to go ahead with elective surgery in a patient with a diastolic

pressure of 110 mmHg or less provided there are no complications of
hypertension.

•Poorly controlled hypertension need:

–ECG, BUN, Creatinine, depending on the surgical procedure.
70
 3. Hypertention..

• Recommended that elective surgery be delayed for severe

hypertension (diastolic BP >115 mm Hg, systolic BP >200 mm
Hg) until BP is less than 180/110 mm Hg.

• If severe end-organ damage is present, the goal should be to

normalize BP as much as possible before surgery.

• Effective lowering of risk may require 6 to 8 weeks of

therapy to allow regression of vascular and endothelial
changes, but too rapid or extreme lowering of BP may
increase cerebral and coronary ischemia; therefore, the
benefits of delaying surgery for treatment must be weighed
against the risks.
71
 3. Hypertention..
• Studies suggest that hypotension intraoperatively is far more dangerous
than hypertension. Continuation of antihypertensive treatment
preoperatively is critical

• Guidelines suggest that cardioselective β-blocker therapy is the best

treatment preoperatively because of a favorable profile in lowering
cardiovascular risk.

• Though diuretics are first-line therapies in most circumstances, starting

them in the preoperative period is not generally a good idea because of the
alterations in potassium (both hypokalemia and hyperkalemia)

• Calcium channel blockers (e.g., amlodipine, 5 to 10 mg daily) can be very

effective. Frequently, anxiety increases BP, and therefore antianxiolytics can
be used as adjunctive therapy
72
 4. Arrhythmias

• Arrhythmia is not a contraindication for surgery but

an attempt must be made to correct the arrhythmia
to the best possible degree,

– e.g. in atrial fibrillation the ventricular rate must be

reasonably slowed with digoxin or beta-blocker before
anaesthesia.

• The arrhythmia must not be severe enough to

interfere with the patient's cardiac output
73
 5. Murmurs and Valvular Abnormalities

• Benign murmurs occur with high-outflow states

– hyperthyroidism, pregnancy, or anemia.

• Noncardiologists or even cardiologists often cannot distinguish benign from

pathologic murmurs

• Echocardiography may be useful dx murmurs,

• Diastolic murmurs are always pathologic and require further

evaluation.

• Regurgitant disease is tolerated perioperatively much better than

stenotic disease

74
 5. Murmurs and Valvular Abnormalities..

• Aortic Stenosis
– Generally, chronic insufficiency is well tolerated in
the perioperative period.

– Patients with good functional status and preserved

left ventricular systolic function have a low risk of
complications with anesthesia.

– Prophylaxis for infective endocarditis is no longer

recommended
75
 5. Murmurs and Valvular Abnormalities..

•Mitral Stenosis
–If patient has a hx of dyspnea, fatigue, orthopnea, pulmonary edema, and
hemoptysis.
•These findings result from elevated left atrial pressure and decreased cardiac
output.

–A preoperative ECG is necessary and an echocardiogram should be considered

if it will change management

–β-Blockers are used to control HR, and antiarrhythmics prevent or control atrial
fibrillation.

–Anticoagulation is managed in conjunction with the treating cardiologist and

surgeon.

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 5. Murmurs and Valvular Abnormalities..

• Mitral Regurgitation
– Preoperative symptoms are vague and often
attributed to other causes.
– Fatigue, dyspnea, and atrial fibrillation can be present
– A loud murmur associated with a thrill (grade ≥4) has
a specificity of 91% for severe regurgitation but a
sensitivity of 24%.
– Chronic mitral regurgitation is generally well
tolerated perioperatively unless other valvular lesions
(e.g., mitral or aortic stenosis) ]
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 5. Murmurs and Valvular Abnormalities..
• Mitral Valve Prolapse
– Also known as click-murmur or floppy valve syndrome
– Commonly diagnosed in young women during
evaluation for atypical chest pain, palpitations, or
syncope.
– Preoperatively is to differentiate patients with clinically
significant mitral valve degeneration and regurgitation
from those with an incidental finding of prolapse
– Patients taking β-blockers for control of palpitations or
atypical chest pain continue these medications
perioperatively.

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 5. Murmurs and Valvular Abnormalities..

• Tricuspid Regurgitation
– Usually asymptomatic and not audible on physical examination
– Noted by echocardiography performed for other reasons.
– Is most commonly caused by dilatation of the right ventricle
and the tricuspid annulus.

– Right ventricular dilatation is caused by conditions that directly

involve the right ventricle
• (ischemia, cardiomyopathy) or is due to pulmonary hypertension and
elevated right ventricular systolic pressure.

– An echocardiogram should be considered if it will change

management.
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 6. Prosthetic Heart Valves

• Need for anticoagulation, and the planned management of such

patients in the perioperative period.

• Occasionally, patients will have valve-related hemolysis.

• The risk for thrombosis is greatest with multiple prosthetic valves,

followed by valves in the mitral position and then aortic valve
replacements.

• The decision to stop anticoagulants, the duration off anticoagulants,

and the need to “bridge” with a shorter-acting drug and the type of
bridging agent (intravenous heparin or [LMWH]) need to be made in
conjunction with the treating cardiologist and surgeon.

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 D. Diabetes mellitus
• Diabetics are at risk for:
– multiorgan dysfunction,
– renal insufficiency,
– stroke,
– peripheral neuropathy,
– autonomic dysfunction,
– cardiovascular disease being most prevalent.
– Delayed gastric emptying, retinopathy, and reduced joint mobility occur
• Tests done include:
– RBG/FBG/KETONES
– Glycylated haemoglobin .
– Four hourly blood (glucometer) or urinalysis (in the ward) for sugar and acetone
– Glucose tolerance tests

• DM must be first investigated and assessed and then controlled before elective
surgery is performed.

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 Diabetes mellitus..

• DM is considered a CAD equivalent and an intermediate risk factor

for perioperative cardiac complications

• HF is twice as common in men and five times as common in women

with diabetes as in those without diabetes.

• Poor glycemic control is associated with↑ risk for heart failure, and
both systolic and diastolic dysfunction

• Diabetics are at ↑ risk for RF perioperatively and for postoperative

infections.

• Chronic kidney disease is usually asymptomatic until quite advanced.

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 Thyroid disorders

• Require thyroid function tests.

• Both hyperthyroidism and hypothyroidism must be corrected before

elective surgery.

• The danger of "thyroid storm" occurring in the post-operative period

necessitates complete control of the toxic state.

• Mild to moderate dysfunction probably has minimal impact perioperatively.

• Significant hyperthyroidism or hypothyroidism appears to increase

perioperative risk

• Grave's ophthalmopathy or proptosis is more common in smokers.

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 Thyroid disorders..

• Patients taking amiodarone are at risk for hypothyroidism and require

evaluation of thyroid function before surgery.

• Preoperative consultation with an endocrinologist should be considered if

surgery is urgent in patients with clinical thyroid dysfunction.

• Hyperthryoid patients should be treated with β-blockers, antithyroid

medications, and steroids if surgery is urgent.

• Chest radiography or CT is useful to evaluate tracheal or mediastinal

involvement by a goiter.

• Continuation of medications (thyroid replacement and antithyroid drugs

such as propylthiouracil) on the day of surgery is important
 E. Renal

• Preoperative evaluation of patients with renal insufficiency or failure

should focus on the cardiovascular and cerebrovascular systems,
fluid volume, and electrolyte status.

• ARF may be reversible if precipitating factors are identified and

corrected.

• In patients at risk for renal disease (especially those with two of the
following: diabetes, poorly controlled hypertension, advanced age),
an ECG and determination of electrolytes, calcium, glucose,
albumin, BUN, and creatinine should be performed

• A chest radiograph (infection or volume overload), echocardiogram

(for murmurs or heart failure), and stress testing may be indicated
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 Renal..

• Venous access or blood draws from the brachial, cephalic

(antecubital), and central veins in the nondominant
upper extremity should be avoided in patients who may
need fistulas for dialysis in the future.

• Preoperative renal replacement therapy (dialysis)

schedules should be determined, with scheduling of
surgery ideally within 24 hours after dialysis because of
acute volume depletion and electrolyte alterations.

• The creatinine level is often not an accurate indicator of

renal function, especially in elderly individuals.
 Renal..

• The GFR can be reduced 50% or more without a rise in creatinine

• Patients at risk for perioperative renal failure include those with

– preexisting renal insufficiency (the single strongest predictor) or
– diabetes
– those undergoing procedures with the administration of contrast
medium.

• Preoperative identification of at-risk patients alters management,

such as
– hydration,
– administration of sodium bicarbonate,
– a change in the type of contrast medium, and
– avoidance of hypovolemia
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 Renal..

• NSAIDs and COX-2 inhibitors interfere with autoregulation of renal

perfusion and should be avoided or discontinued in patients with or
at risk for renal insufficiency.

• Cyclosporine and aminoglycoside antibiotics can cause renal

insufficiency.

• ACEIs and ARBs prevent deterioration in patients with diabetes or

renal insufficiency but may worsen function during hypoperfusion
states.

• Drugs with particular implications for anesthesia and surgery include

LMWHs because they are metabolized or cleared by the kidneys.
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 F. Psychiatric Disorders

• psychiatric disorders include assessing:

– cognitive capacity,
– obtaining an accurate psychiatric history,
– evaluating the patient's capacity to give informed consent, and
– assessing the impact of psychotropic medications.

• Cognition is usually unimpaired in patients suffering from

illnesses such as depression or schizophrenia and impaired in
those suffering from disorders such as delirium, dementia, and
autism.

• Basic orientation to person, place, and time can be determined

during the preoperative conversation or by looking at the way
the patient has answered questions on forms.

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 Psychiatric Disorders..

• More severe cognitive impairment raises issues regarding

the reliability of the history and ability to obtain informed
consent.

• Family members can aid by providing the history and

countersigning consent forms.

• Preoperative evaluation by history and physical examination

focuses on the skeletal and cardiopulmonary systems.

• A murmur warrants an ECG and may benefit from an

echocardiogram.
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 G. Fluid Imbalance

• Electrolytes, CVP
– Whenever possible the volume of circulating fluid
should be corrected before anaesthesia.
– Briefly, the following symptoms and signs suggest
dehydration:
Thirst Dry mouth , Diminished skin turgor, Rapid
pulse,Decreased urine output.
– In the later stages a fall in blood pressure CVP if
measured will be low
– A high BUN and a raised specific gravity of urine
confirm the diagnosis
– The appropriate fluid must be administered with a
close watch on these parameters.
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 F. Electrolyte imbalance..

• Sodium and potassium imbalance especially must be

corrected pre-operatively

• A low potassium level can result in hypotension, arrhythmias

and cardiac arrest.

– It can also result in skeletal and smooth muscle weakness and

interfere with the action of relaxant drugs.

• A high potassium level is also associated with cardiac

arrhythmias.

• Fluid and electrolyte imbalance will be more common in

patients for emergency surgery.
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 H. OTHERS
• Liver disease

– Liver function tests & especially in relation to the

prothrombin index.

– After a severe case of infective hepatitis, operation

is best postponed for a minimum of six months.

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 SPECIAL PROBLEMS RELATED TO EMERGENCY SURGERY

• Hypovolaemia:
– Treated 1st
– Correct fluid imbalance
– cross matching of blood should be underway before anaesthesia
commences 

• The un-fasted patient (full stomach)

– Dangers of vomiting or regurgitation under anaesthesia
– Pre-operative measures taken to prevent this complication include:
• Postpone surgery for at least six hours.
• However, the gastric emptying time is usually prolonged in emergencies.
• The stomach may be emptied using an NGT or orogastric tube of the largest
possible bore.
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 Summary: Key points on pre-anesthetic evaluation
1. Preoperative laboratory testing should be selective and individualized.
2. Current ACC/AHA guidelines for cardiac testing prior to noncardiac
procedures are the gold standard for preoperative cardiac risk
assessment.
3. The most important preanesthetic evaluation includes a thorough,
accurate, and focused history and physical examination.
4. A patient’s baseline hemoglobin tends to predict the need for transfusion
when large blood loss occurs.
5. The four active cardiac conditions that will likely result in surgical
cancellation to assess cardiac evaluation and treatment are unstable
coronary syndrome, decompensated heart failure, significant cardiac
arrhythmias, and severe valvular disease.
6. Before halting a patient’s anticoagulation, one must consider the type and
urgency of surgery, the possibility and consequences of intraoperative
hemorrhage, and the reason why the patient is anticoagulated
 REFERENCE
• Miller Anaesthesia 7th ed
• Morgan & Mikhail’s Clinical anaesthesia 5th Ed
• James Duke, Brian Keech-Duke's Anesthesia
Secrets-Saunders (2015)

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