بسم ال الرحمن الرحمن

Pre-Operative Assessment Of Surgical Patients

• Pre-operative assessment has four goals:-

1.to acquire the relevant information about the patient's state

2.to educate the patient

3.to diminish anxiety

4.to obtain informed consent from the patient for the proposed procedure.

• The assessment should determine:-1. the nature and extent of the relevant surgical

pathology2. the nature and extent of any disease which might

affect the conduct of the operation and postoperative course

3. Any specific problems that might affect choice of anaesthesia and postoperative care

History

• Present illness (including age, sex, complaint, planned procedure, elective/ emergency?)

• Past Medical History:-

1.List of medical problems

2.Medications, allergies, drug history, recreational drug use

3.Past surgeries, type of anesthetic used, anesthetic related problems

• Family History:-

1.Any anesthetic related problems• Social History:-

1.Smoking, alcohol, STDs, HIV etc

Systemmic Review

• General:-1.Vital signs2.Exercise tolerance, weakness, fatigue, fever,

weight changes, frequent headaches• Skin:-1.Rashes, sores, lesions• Eyes:-1.Double vision, blurring, glaucoma, cataract

Ear:-•Vertigo, dischargeMouth:-•Bleeding gums, dentures, loose teethCardiovascular system:-•MI , CCF , murmurs, angina, palpitations•peripheral oedema

• Respiratory system:-

1.Cough, sputum, haemoptysis, asthma, TB• GI:-

1.Hiatus hernia, GERD, diarrhoea, constipation, haematemesis, maleana, jaundice, hepatitis

• Urinary system:-

1.Frequency, urgency, nocturia, dysuria, haematuria, incontinence

• Female:-

1. LMP, likelihood of current pregnancy• Neurologic:-

1. seizure, stroke• Haematologic:-

1. Anaemia, past transfusions• Endocrine:-

1. Thyroid abnormalities, diabetes

• The most common general assessment of fitness used by anaesthetists is the American Society of Anesthesiologists' (ASA) .

ASA Classification

1. A normal healthy patient2. A patient with mild systemic disease3. A patient with severe systemic disease4. A patient with severe systemic disease that is a

constant threat to life5. A moribund patient who is not expected to

survive without the operation (E)6. A declared brain-dead patient whose organs are

being removed for donor purposes.

Investigations

• A full blood count (FBC) is generally requested to detect anaemia, which may place the individual at risk from a general anaesthetic

• Coagulation profile if necessary

Biochemistry

• All patients should have a dipstick urinalysis to measure glucose, bilirubin, protein and ketones.

• In patients aged under 60 years, this is sufficient

• Serum sodium and potassium• hyperkalaemia can predispose to cardiac

arrest, particularly if suxamethonium is given • hypokalaemia can lead to cardiac arrhythmias.

• Urea and electrolytes are requested if :

1. Clinical evidence of renal disease.

2. Symptomatic cardiovascular disease.

3.Diabetes.

4.Drugs-Diuretics, digoxin, steroids

• Liver function tests

1.Clinical evidence of liver disease.

2.Chronic liver disease, including a history of hepatitis.

Preoperative Chest X Ray

• to confirm or establish a diagnosis and

evaluate the extent of pathology• to establish a baseline for comparison with

postoperative films

1. Cardiorespiratory disease.

2. Possible pulmonary malignancy (primary or secondary).

3. Severe trauma.

4. Immigrants from countries with endemic TB.

ECG

• Abnormalities are relatively common, between 47% and 52% and correlate with increasing age.

• only 1.6% of patients with abnormal preoperative ECGs experience a perioperative adverse cardiovascular event

• In only half of these the preoperative ECG was helpful.

1. Patients older than 60 years undergoing major surgery.

2. Symptoms and signs of cardiovascular disease, including ischaemic heart disease or hypertension.

3. Symptomatic respiratory disease.

Airway Assessment

• Difficult tracheal intubation accounts for 17% of the respiratory related injuries and results in significant morbidity and mortality.

• Up to 28% of all anaesthesia related deaths are secondary to the inability to mask ventilate or intubate

• A global assessment should include the following:

1.Patency of nares : masses inside nasal cavity (e.g. polyps) deviated nasal septum, etc.

2.Mouth opening of at least 2 large finger breadths between upper and lower incisors in adults is desirable.

Preoperative Fasting Guidelines

Preoperative fasting guidelines The volume of liquid ingested is less important than the type of liquid

ingested.

Intake of water up to 2 hrs before induction of anaesthesia.

Other clear fluids *, clear tea and coffee without milk up to 2 hrs before induction of anaesthesia.

Tea and coffee with milk are acceptable up to 6 hrs before induction of anaesthesia.

The volume of administered fluids does not appear to have an impact on patient’s residual gastric volume and gastric pH, when compared to a standard fasting regimen.

Therefore, patients may have unlimited amounts of water and other clear fluid up to two hours before induction of anaesthesia.

The intake of solid foods A minimum pre-op fasting time of 6hrs is

recommended for food (solids and milk). Fried or fatty meal 8hrs is recommended before

induction of anaesthesia.

Chewing gum and sweets Chewing gum should not be permitted on the day of

surgery. Sweets are solid food. A minimum of 6hrs pre-op

fasting time is recommended.

• Higher-risk patients should follow the same pre op fasting regime as healthy adults, unless contraindicated.

• Adults undergoing emergency surgery should be treated as if they have a full stomach.

• If possible, the patient should follow normal fasting guidance to allow gastric emptying.

• High risk of regurgitation and aspiration; patients include those with obesity, gastro-oesophageal reflux and diabetes.

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