Pre anesthetic checkup

1. PRE ANAESTHESIA CHECKUP
BY –
DR NAVEEN (MODERATOR)
DR MALLIKA KULKARNI – JR1 DNB ANESTHESIOLOGY

2. PAC –
Process of clinical assessment that precedes the delivery of anesthesia for surgical
and non surgical procedures
The fundamental purpose of preoperative evaluation is to obtain pertinent information
regarding
 the patient’s medical history
 formulate an assessment of the patient’s perioperative risk
 develop a plan for any requisite clinical optimization
Ensure that the patient can safely tolerate anesthesia

3. Objectives of PACs
 Doctor patient rapport
 Patient data
 Anesthesia plan
 Patient consent

5. Time of Evaluation
 The Joint Commission mandates documentation of a history and physical
examination for any surgical patient within 30 days before the planned procedure
 reassessment within the 48-hour period immediately
 preceding the surgical procedure

6. Components of Medical history

11. Assessment of Functional Capacity
 Anesthesiologist will inquire about a
patient’s general activity levels during PAC,
subjective assessment of the patient’s
functional capacity.
 Functional capacity is typically quantified
in using the metabolic equivalent of task
(MET), where one MET is approximately
the rate of energy consumption at rest
(3.5 mL/kg/min)

12. Physical Examnation
 Vital signs - arterial blood pressure, heart rate,
respiratory rate, oxygen saturation
 height and weight

13. Components of the Airway Examination
 Length of upper incisors (concerning if relatively long)
 Condition of the teeth
 Relationship of maxillary incisors to mandibular incisors (concerning if there is prominent overbite)
 Ability to advance mandibular incisors in front of maxillary incisors (concerning if unable to do this)
 Inter incisor or intergum (if edentulous) distance (concerning if < 3 cm)
 Visibility of the uvula (concerning if Mallampati class is 3 or more)
 Shape of uvula (concerning if highly arched or very narrow)
 Presence of heavy facial hair
 Compliance of the mandibular space (concerning if it is stiff, indurated, occupied by mass, or nonresilient)
 Thyromental distance (concerning if < 6 cm)
 Length of the neck
 Thickness or circumference of the neck
 Range of motion of the head and neck (concerning if unable to touch tip of chin to chest or cannot extend
neck)

14. Modified Mallampati Classification
 Sitting position
 Mouth fully open
 Tongue protruding
 Observer’s eye at the level of patient’s open mouth

15. AIRWAY SCORING INDICES
 Benumof’s 11 parameter analysis
 Wilson scoring system
 Rocke’s risk probability
 Arne’s simplified score model
 Magbuul score 4M and 4D

17. PAC with Coexisting diseases
Cardiovascular diseases
Hypertension
 Based on revised 2017 ACC/AHA guidelines, hypertension is defined as a blood pressure greater
than 130/80 based on appropriately measured arterial blood pressure
 Etiology and Severity of hypertension.
 End organ damage due to hypertension.
 Ongoing Anti-hypertensive therapy
 patients with long-standing, severe, or poorly controlled hypertension should undergo
 an ECG and blood sampling to measure creatinine concentration.
 Individuals on diuretic antihypertensives (e.g., chlorthalidone, hydrochlorothiazide) may require
evaluation of electrolytes

18.  Ask for the following complaints.
 Headache
 Chest Pain
 Exercise intolerance, Shortness of
breath
 Dependent edema
 Postural lightheadedness, Syncope
 Claudication
 Current Anti-hypertensive therapy

19. Recording Blood Pressure
3 pre-recording pt. requisites
 No tea / coffee for 30 mins
 No smoking for 30 mins
 Empty urinary bladder
3 pre-requisites for patient position
 Rested in sitting position for 5 mins
 Sitting with arms resting on sidearm
 Appropriate width/length of cuff conditions for actual BP recording
Inflate cuff to 30 mmHg > palpated systolic BP
Take 2 readings 2-3 mins apart till readings ± 5 mmHg difference
Record both pulse & BP to rule out anxiety

20.  Preoperative hypertension is associated with an increased risk of cardiovascular
complication,84 this association is generally not evident for SBP values less than
180 mm Hg
 All long-term antihypertensive treatment should be continued up to the day of
surgery, with the possible exception of (ACEIs) and (ARBs)
 Administration of these medications within 24 hours before surgery is consistently
associated with increased risks of intraoperative Hypotension and possibly
associated with elevated risks of postoperative myocardial injury
 They are restarted postoperatively once patients are hemodynamically stable.

21. Heart Failure

22. BNP concentrations above 300 ng/L or NT
pro-BNP concentrations above 900 ng/L are indicative of patient at high cardiac risk

23. Respiratory System
History suggestive of pre-existing lung disease:
 URTI
 Asthma -Features recent exacerbations, therapy
 Obstructive lung disease
 Restrictive lung disease
 H/O exacerbation with anaesthesia
 Quantitatively Document Tobacco exposure as PACK YEARS (No. of pack of
cigarettes/day × No. of years)

24. Benefits of smoking Cessation
 12-24 h COHb & Nicotine levels decreased.
 48-72 h COHb levels normalize & ciliary functions start improving.
 1-2 weeks Sputum production start decreasing.
 4-6 weeks PFTs improve, if deranged.
 6-8 weeks Immune functions & drug metabolism normalise
 8-12 weeks Overall postoperative morbidity decreases
 Adverse effects of short term cessation: Withdrawal symptoms, tenacious secretions

26. Endocrine System
DIABETES MELLITUS
 Assessment of organ damage.
 Control of blood sugar.
Ask for
 Suggestive symptoms (eg, polyuria/ polydipsia)
 Frequency, severity.
 Complications (i.e., ketoacidosis, hypoglycemia)
 Symptoms and treatment of chronic complications.
 Current antidiabetic therapy and compliance.

27. THYROID DISORDERS
 symptoms suggestive of hypo- or hyperthyroidism.
 symptoms related to goitre.
 current medical therapy.
HYPOTHALAMIC-PITUITARY-ADRENAL DISORDER
 Cushing’s syndrome or Addison’s disease or Pheochromocytoma

28. Renal System
 urine output - oliguria, anuria, polyuria
 swelling of face, legs, whole body
 dialysis related history (mode and time of last dialysis)
 weight changes (fluid assessment)
 electrolyte status
 anemia and bleeding tendency

29. Hepatic System
 Jaundice
 Pruritis or other skin changes (spider navi ,white nails)
 Abdominal pain
 Abdominal lump
 Ascites
 Stigmata of chronic liver disease

30. Hematological System
 Unusual bleeding
 Clotting disorder
 Sickle cell disease
 Anemia

31. Nervous System
 Cerebrovascular accident.
 Seizure disorder (duration, adequacy of control, anticonvulsant therapy).
 Neuromuscular junction disorders (Myasthenia gravis, Lambert-Eaton synd.)
 Muscular dystrophies.
 RTA/head injury.

32. PAC In Pediatric
 Perinatal history: congenital anomaly preterm infants: susceptible for apnea, systemic
infection, resp distress syn, intraventricular hemorrhage. So they often require ventilator
support.
 Anesthetic history: highlight for perioperative nausea & vomiting, traumatic, gaseous
induction, difficult IV access & family h/o malignant hyperthermia or suxamethonium
apnea
 Medical history : patency of airway & cardio respiratory functions are important
 RS : h/o snoring, recent URTI, purulent runny nose, loss of
 appetite, disturbed sleep pattern.
 If murmur present proceed with anaesthesia if child is: >1yr
 asymptomatic normal ECG and should not be pathological murmur

33. PAC In Geriatric Patient
 One should have high index of suspicion for diseases commonly associated with aging. Common diseases of
elderly may have a major impact on anaesthetic management & require special care & diagnosis.
 It is important to determine cognitive status as dementia is common in elderly population. Pre-op cognitive
deficit has a direct bearing on post op emergence and peri op morbidity. It is a predictor of post op
delerium.
 For purposes of PAE, the mini mental state examination
 Allows for quick screening of baseline cognitive status
 Airway –look for loose tooth,artificial tooth,eduntulous,loss of buccal pad of
 fat
Other issues in elderly are:
 Malnutrition
 Depression
 Immobility
 Dehydration
 Alcoholism
 Chronic pain

34. PAC For Obstetric Patient
 The anesthesiologist should be aware of the present and relevant history.
 History should include: age, parity, duration of the pregnancy, and any complicating factors.
 Patients definitely requiring anesthetic care (for labor or cesarean section) - should undergo a
preanesthetic evaluation
 This consists of a maternal health history, anesthesia related obstetric
 history, BP measurement, airway assessment, and back (spine)examination
 These pts are always considered to be full stomach & there is increased risk of aspiration
{Mandelson’s syndrome}
 Incidence of failed intubation is higher in obstetric pt, so airway should be assessed carefully

35. Preoperative Lab and Diagnostic Tests
 CBC
 ECG Advanced age >40yrs, Cardiovascular disease, Respiratory disease
 Chest X-Ray
History or signs of cardiac or resp disease, malignancy, planned thoracic surgery
 PFT
Moderate to severe dyspnea on mild to moderate exertion Reactive airway disease COPD Scoliosis
 ABG Analysis
 Elective major surgery with expected fluid shifts/ thoracotomy, Dyspnea at rest
 Urea & Electrolytes Pts. on digoxin, diuretics, steroids, Diabetes, renal disease, diarrhea, blood
loss
 Liver Function Tests H/O alcohol intake, Malnutrition, metastatic disease

36.  Blood Sugar Estimation Diabetics, Pts. with peripheral arterial disease, on steroids
 Coagulations Tests Anticoagulants, bleeding disorder, liver or renal disease

37. Perioperative Risk Assessment
 American Society of Anesthesiologists Physical Status Classification
 Category Definition
 ASA-PS 1 A normal, healthy patient
 ASA-PS 2 A patient with mild systemic disease
 ASA-PS 3 A patient with severe systemic disease
 ASA-PS 4 A patient with severe systemic disease that is a constant threat to life
 ASA-PS 5 A moribund patient who is not expected to survive without the operation
 ASA-PS 6 A declared brain-dead patient whose organs are being removed for donor
purposes
 *The addition of “E” to the classification category indicates emergency surgery.

38. Informing the Patient
 Explaining main events of perioperative period.
 Allow the patient to ask questions.
 NPO status & medications.
 All about premedication.
 Invasive monitoring devices specially if to be used during preanesthesia
period.
 Anesthetic techniques in simple language.
 Recovery period – drains, catheters etc.
 Post operative pain control
 Take Anesthesia Consent

39. NPO Guidelines

40. Preoperative Medical Management

41. HANDY ADVICE
 Detachable Artificial limbs, artificial eyes, contact lenses, to be removed.
 To bring the artificial dentures, if used any, to the operation theatre.
 To come to OT with all the advised investigations.
 Hearing aids to be retained.
 Empty the bladder before coming to the OT.
 Detachable Artificial limbs, artificial eyes, contact lenses, to be removed.
 To bring the artificial dentures, if used any, to the operation theatre.
 To come to OT with all the advised investigations.
 Hearing aids to be retained.
 Empty the bladder before coming to the OT.

42.  The anesthesia preoperative evaluation is the clinical foundation and
framework of perioperative patient management.
 The anesthesia preoperative evaluation clinic can enhance operating room
efficiency, decrease day-of-surgery cancellations and delays, reduce hospital
costs, and enhance the quality of patient care
 The anesthesiologist is the perioperative medical specialist and the only
preoperative evaluation physician who can truly evaluate the risks associated
with anesthesia, discuss these risks with the patient, and manage them
intraoperatively.
Thank You!