? Surgical procedures performed under anaesthesia require
preoperative evaluation
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- Anaesthesia is an added risk to surgery
- Preanaesthetic evaluation of patients improve clinical safety
- Minimizes morbidity in appropriately prepared patient
Purpose
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? To obtain pertinent information regarding.
? The patient's medical history,
? Formulate an assessment of the patient's
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perioperative risk
? Develop a plan for any requisite clinical
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optimization.? Planning postoperative pain management in the
background of preoperative pain medication
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Goals of Preoperative evaluation
? To ensure that patients can safely tolerate
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anaesthesia for planned surgical procedures? To mitigate risks associated with the overall
perioperative period
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Scope of Preoperative Evaluation? General History (leading question based)
? Physical examination
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? Evaluation of coexisting disease? Preop lab and diagnostic investigations
? Preop medication management
History
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vCorrect diagnosis can be made in 56% ofcases on the basis of history alone
? History in general
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? History of coexisting medical illnesses? History of taking medicine
? History of allergies and drug reactions
? Anaesthetic history
? Family History
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Physical examination
? Special attention to the evaluation of the
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? vital signs, (CNS, heart, lung,)? Airway,
?If regional anaesthesia is proposed :
? Assessment of the site of block
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? BackHeight and weight
? Calculate BMI : obese
? Estimate drug dosages
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? Determine fluid volume requirement? Calculate acceptable blood loss
? Adequacy of urine output
Vital signs
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? Blood pressure
? Resting pulse
- rate, rhythm, and fullness
? Respiration
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- rate, depth, and pattern at rest? Body temperature
? Pain score (baseline score)
Airway Examination
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? Mallampati classification? Interincisors gap
? Thyromental distance
? Forward movement of mandible
? Range of cervical spine motion :
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flexion and extension? Document loose or chipped teeth,
tracheal deviation
Preoperative Evaluation Of
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Patients With Coexisting Disease
? Identification of these comorbid conditions often
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presents an opportunity for the anaesthesiologist tointervene to decrease risk
? These conditions are best managed before the
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surgery, thus allowing ample time for thoughtfulevaluation, consultation, and optimization.
Cardiovascular system
? May lead to serious perioperative adverse events
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? Cardiovascular complications account for almost half
of the perioperative mortalities
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? Serious myocardial injury occurs in approximately80% of patients who undergo major surgery
? Some perioperative interventions modify risks for
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cardiovascular morbidity and mortality
Cardiovascular disorders
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? Hypertension? Ischemic heart disease
? Heart failure
? Valvular heart disease
? Patients with rhythm disturbances
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? Patient with coronary stents? Patients with pacemakers and ICD devices
? Patients with peripheral arterial disease
The Revised Cardiac Risk Index (RCRI) has been
extensively validated for predicting perioperative cardiac
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risk in noncardiac surgeryMETS
Fliesher et al. "2014
ACC/AHA Guideline
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on PerioperativeCardiovascular
Evaluationand
Management of Patients
Undergoing Noncardiac
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Surgery."http://content/onlinejac
c.org/
Respiratory system
? Respiratory function is inextricably linked to practice
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of anaesthesia
? GA has significant effects on respiratory function and
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lung physiology and mechanics? Adverse respiratory event can occur during
anaesthesia and the most significant is hypoxemia
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? Integrative measures of respiratory function are likely
predictors of outcome following anaesthesia and
surgery
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Pulmonary disorder
? Upper respiratory tract infection
? Asthma and COPD
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? Chronic smokers? Restrictive lung diseases
? Obstructive sleep apnoea
? Patients scheduled for lung
resection
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Endocrine system? Diabetes Mellitus
? Thyroid disorders
? Hypothalamic- pituitary- adrenal disorders
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? PheochromocytomaRenal system
? Surgical stress, anaesthetic agents tend to decrease
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GFR
? Renal impairment- CKD
- AKI
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? Contrast induced nephropathy? The emphases of the preoperative evaluation of
patients with renal insufficiency are on the
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cardiovascular system, cerebrovascular system, fluid
volume, and electrolyte status
Hepatic disorder
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? Liver diseases have significant impact on drug
metabolism and pharmacokinetics
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? Sedatives./opioids might have exaggerated effects inpatients with advanced liver disease
? Hepatitis
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? Alcohol liver disease? Obstructive jaundice
? Cirrhosis
Hematologic Disorders
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? Anaemia
? Sickle cell disease
? G6PD deficiency
? Coagulopathies
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Neurologic disease? Cerebrovascular disease
? Seizure disorders
? Multiple sclerosis
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? Aneurysm and AV malformation? Parkinson disease
? Neuromuscular junction disorders
? Muscular dystrophy and myopathy
Musculoskeletal and Connective tissue disorders
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? Rheumatoid Arthritis
? Ankylosing Spondylitis
? Systemic Lupus Erythematosus
? Raynaud Phenomenon
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Miscellaneous conditions
? Morbidly obese patient
? Patient with transplanted organs
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? Patient with allergies? Patient with substance abuse
Specific group of patient
? Children
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? Pregnant patient? Breast feeding patient
? Elderly patient
Preoperative laboratory and diagnostic studies
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? To screen the disease
? To evaluate fitness for surgery
? Should be based on patient's medical history and
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proposed surgical procedurePreoperative diagnosis based investigations
before elective surgery
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Preoperative risk assessment? A critical objective for the preanaesthesia evaluation
? Improves patients' understanding of the risks inherent
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to the perioperative period? Helps health care providers for clinical decision
making
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? Helps to identify individuals who warrant potentially
beneficial interventions, enhanced levels of
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postoperative monitoring, or consideration foralternative nonoperative treatment for their
underlying condition
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Risk stratification? Meyer Saklad et al- 1941, described `six degree' ASA
PS grading of a patient's physical state as just one of
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the components of the operative risk
? He listed the other components as:
-The planned surgical procedure
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-The ability and skill of the surgeon in the particularprocedure contemplated
- The attention to postoperative care
- The past experience of the anaesthetist in similar
circumstances
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Influences of various components on poor perioperative
outcome
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Preoperative medication management? Medications: to continue or not?
? Need to understand risk/ benefit of continuing or holding
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a medication? Diuretics, ACE Inhibitors, ARBS
- should be discontinued 12-24 hr prior to surgery to prevent
intraoperative hypotension
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? Nitrates, Digoxin, Clonidine, Beta Blockers, CalciumChannel Blockers, and Antiarrhythmic drugs
-Essentially safe to continue perioperatively
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Planning for postoperative pain management
? All patients have the right to appropriate assessment
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and treatment of pain? A preoperative evaluation should include baseline
pain assessment
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? Provides an important opportunity to discuss and plan
for the management of acute postoperative pain
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? Specific issues include their tolerance to usual dosesof opioid analgesics and the potential for acute
withdrawal reactions should be assessed
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Collaboration, Commitment and Team work? The preoperative evaluation clinic is a visible partnership among the
departments of anaesthesia, surgery, nursing, and hospital administration to
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achieve common goalsSummary
Surgeries done (w.e.f 3/6/14 till date)
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LA, 930GA, 901
? OPD based Preoperative
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evaluation was done
? Grave morbidity- 7 cases
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(0.003%)Regional213