perioperative evaluation of surgical patients

1. PREOPERATIVE
EVALUATION

2. Goals
■ Gather and record all relevant information
■ Optimise patient condition
■ Choose surgery that offers minimal risk and maximum benefit
■ Anticipate and plan for adverse events
■ Inform everyone concerned

3. Patient assessment
■ History Taking
– Ask for chief complaints with duration
– History of present illness
– History of past illness
– Personal history
– Family history
– Treatment history
– History of any Allergy

4. ■ General examination
– Built/Nutritional status
– Pulse
– Blood pressure
– Respiratory rate
– Temperature

5. – Pallor
– Clubbing
– Oedema
– Jaundice
– Neck veins (any visible veins, jugular venous pressure)
– Neck glands (local lymph node status, salivary glands)
– Skin (any scar marks, drug abuse injection sites, local infections)

6. Systemic examination
– Cardiovascular: Pulse, blood pressure, heart sounds, murmurs,
bruits, peripheral oedema
– Respiratory: Respiratory rate and effort, chest expansion and
percussion note, breath sounds, oxygen
saturation
– Gastrointestinal: Abdominal masses, ascites, bowel sounds,
hernia, genitalia
– Neurological: Consciousness level, cognitive function, sensation,
muscle power, tone and reflexes

7. Investigations
■ The UK National Institute of Health and Clinical Excellence (NICE)
guidelines:
– Full blood count (CBC)
– Urea and electrolytes (sodium, potassium, bicarbonates)
– Electrocardiography
– Clotting screen (PT, APTT, INR)
– Chest radiography

8. – Blood glucose levels (FBS, PPBS) and HbA1c
– Arterial blood gases
– Liver function tests (ALT, AST, ALP, bilirubin)
– Urinalysis
– B-Human chorionic gonadotrophin (to exclude pregnancy)
– Other investigations (as per indications)

9. Preoperative management of patients
with
systemic disease
■ Capacity: Baseline organ function capacity should be assessed
■ Optimisation: Medication, lifestyle changes, specialist referral will improve
organ capacity
■ Alternative: Minimally impacting procedure, appropriate postoperative care
will improve outcomes
■ Theatre preparations: Timing, teamwork, special instruments and equipment

10. Checklist for optimal preoperative
assessment of Geriatric surgical patients
■ Assess Patient’s Cognitive ability
■ Screen for depression
■ Identify risk factors for developing post-op delirium
■ Screen for substance abuse/dependence
■ Cardiac evaluation

11. ■ Pulmonary evaluation
■ Determine baseline Frailty score
■ Document functional status and history of falls
■ Assess patients nutritional status
■ Accurate and detailed medication history
■ Determine patient’s family and social support system

12. Cognitive assessment with Mini-Cog
■ Tell the patient 3 words and ask him to say it, remember it and
repeat it later
– Give 3 tries to patient to repeat. If unable, proceed to next
– Scoring: 3 items recall (0-3 points)
■ Ask to draw a clock in a circle on a paper and put the numbers in
order and set the time to 10 past 11
– If subject is unable to finish the clock in 3 minutes; discontinue and ask him to
recall the 3 words
– Clock draw score: (0 or 2 points)
■ Say: “what were the 3 words I asked you to remember?”

13. Functional assessment
Functional capacity MET Range Examples
Poor <4 Sleeping, writing, watching tv
Moderate 4-7 Climbing a flight of steps,
slow bicycling
Good 7-10 Jogging, aerobics
Excellent >10 Rope jumping
Functional status is assessed from patient’s activities of daily living”(ADLs) and
expressed in metabolic equivalents (METs)
1 MET = avg O2 consumption of a 40yr old male

14. Frailty score
Shrinkage Unintentional weight loss>10 past year
Weakness Decreased grip strength
Exhaustion Self reported poor energy and endurance
Low physical activity Low weekly energy expenditure
Slowness Slow walking
Criteria Definition

15. SYSTEMS
APPROACH TO
PREOPERATIVE
EVALUATION

16. Cardiovascular system
■ Revised Cardiac Risk index:
Points
1. H/o ischemic heart disease 1
2. H/o congestive heart failure 1
3. H/o cerebrovascular disease ( stroke or TIA)
1
4. H/o diabetes requiring pre-op insulin use 1
5. Chronic kidney disease (Sr. creatinine: >2mg/dl) 1
6. Undergoing suprainguinal vascular, intraperitoneal or intrathoracic surgery
1

17. Risk for cardiac death, non fatal MI, and non fatal cardiac arrest
0 predictors: 0.4%
1 predictor: 0.9%
2 predictors: 6.6%
>=3 predictors: >11%

18. ■ Patients who experience MI after non cardiac surgery have
hospital mortality of 15%-25%
■ Risk factors :
– Age>70 yrs
– Unstable angina
– Recent MI(<6 mnths)
– Untreated CHF
– Diabetes mellitus
– Valvular heart disease
– Arrhythmias
– Peripheral vascular disease

19. ■ Patients with pacemakers should have them turned to uninhibited
mode before surgery
■ Bipolar cautery should be preferred over unipolar
■ Patients with internal defibrillators should have device turned off
during surgeries
■ Recent studies, POISE trial suggest that beta blockers reduce
peri-operative ischemia, risk of MI and death in high risk patients.
■ Each patients dose should be titrated to achieve adequate benefit
from beta blockade while avoiding risk of hypotension and
bradycardia

20. ■ Current guidelines are to delay non cardiac surgery at least 6
weeks after coronary angioplasty or stenting
■ Because they require 6 weeks of dual antiplatelet therapy
■ Placement of drug eluting stents requires 12 months of dual anti
platelet therapy
■ Elective surgeries should be postponed for this period

21. Pulmonary system
■ Current respiratory status should be compared with their normal state
■ The following should be noted:
– regular treatment records of PEFR
– use of steroids
– home oxygen and continuous positive airway pressure (CPAP)
ventilation
– evidence of right heart failure

22. Risk factors for pulmonary
complications
■ Patient related factors:
– Age >60yrs
– COPD
– CCF
– OSA
– Pulm. HTN
– Smoking
– Preoperative sepsis
– Weight loss >10% in 6 months
– Serum albumin <3.5mg/dl, BUN >21mg/dl, Sr. Creatinine >1.5mg/dl

23. ■ Surgery related factors:
– Prolonged operation >3hr
– Site of surgery
– Emergency operations
– General anaesthesia
– Perioperative transfusion
– Residual neuromuscular blockade after an operation

24. ■ Preoperative interventions that may decrease post-op pulmonary
complications are:
– Smoking cessation (within 2 months of surgery) --- bailey
■ Current guidelines favor cessation regardless of any time frame
– Bronchodilator therapy
– Antibiotic therapy for pre-existing infections
– Pre treatment of asthmatics with steroids
– Pulmonary toilet
– Incentive spirometry

25. ■ Physical examination should be focussed on signs of any lung
disease
– Wheezing
– Prolonged inspiratory-expiratory ratio
– Clubbing
– Use of accessory muscles of respiration
■ A chest XRAY should only be performed for acute symptoms,
unless it is indicated for the specific procedure
■ ABG can be considered in patients with H/O lung disease and acid
base abnormality
■ PFT is controversial and unnecessary in stable patients

26. Gastro-intestinal system
■ Nil by mouth and regular medications
– Patients are advised not to take solids within 6 hours
– Clear fluids (isotonic drinks and water) within 2 hours
– Infants are allowed a clear drink up to 2 hours
– mother’s milk up to 3 hours
– cow or formula milk up to 6 hours ------bailey
■ Patients can continue to take their specified routine medications
■ with sips of water in the nil by mouth period.

27. ■ Regurgitation risk
Patients with
■ hiatus hernia,
■ obesity,
■ pregnancy and
■ diabetes
are at high risk of pulmonary aspiration even if they have been NPM
before elective surgery
H2 blockers and PPIs should be administered in such cases.

28. Hepato-biliary system
■ cause of the disease needs to be known
■ any evidence of clotting problems
■ Renal involvement, and encephalopathy
■ Elective surgery should be postponed until any acute episode has
settled
■ Ascitis, oesophageal varices, hypoalbuminaemia, sodium and water
retention should be noted
■ all these can influence choice and outcomes of anaesthesia and
surgery.

29. Genitourinary disease
■ Renal disease
Underlying conditions leading to chronic renal failure
– diabetes mellitus
– hypertension
– ischaemic heart disease
should be stabilised before elective surgery
Measures should be taken to treat acidosis, hypocalcaemia and
hyperkalaemia of greater than 6 mmol/L

30. ■ Laboratory data:
– Serum electrolytes
– Serum bicarbonate
– Blood urea nitrogen
– Serum creatinine
– CBC - to evaluate anemia and thrombocytopenia
■ Dialysis should be performed, if indicated, within 24 hrs of planned
procedure

31. ■ Risk factors for development of ARF:
– Elevated preoperative BUN or creatinine
– CHF
– Advanced age
– Intraoperative hypotension
– Sepsis
– Use of nephrotoxic and radionucleotide agents
■ Management:
– Adequate hydration
– Use of low osmolality contrast agents
– Bicabonate drip
– Oral N-acetylcysteine

32. ■ Urinary tract infection
1. Uncomplicated urinary infections are common in women
2. outflow uropathy with chronically infected urine is common in
men
■ infections should be treated before embarking on elective surgery
■ For emergency procedures, antibiotics should be started
■ care taken to ensure that the patient maintains a good urine output
before, during and after surgery

33. Endocrine and metabolic disorders
■ Malnutrition
– BMI of less than 18.5 indicates nutritional impairment
– BMI of less than 15 is associated with significant hospital mortality
– Nutritional support for a minimum of 2 weeks before surgery
■ Obesity
– Morbid obesity is defined as BMI of more than 35
– Associated sleep apnoea should use a CPAP device
– If possible, delay surgery until the patients are more active and have
lost weight

34. ■ Diabetes mellitus
– HbA1c levels should be checked
– Patients with diabetes should be first on the operating list
– patient’s blood sugar levels should be checked every 2 hours
– those on the afternoon list
– breakfast can be given with half their regular dose of insulin
– or full-dose oral anti-diabetic agents
– An iv insulin infusion should be started for IDDM undergoing major
surgery or if blood sugar is difficult to control

35. ■ Oral hypoglycemic agents should be discontinued the evening
before scheduled surgery
■ Long acting agents should be stopped 2-3 days prior
■ Patients undergoing major surgery should recieve ½ of their
morning insulin dose and 5% dextrose intravenously
■ Subcutaneous insulin pumps should be inactivated the morning of
surgery

36. ■ Adrenocortical suppression
– Patients receiving oral adrenocortical steroids should be asked
– about the dose and duration of the medication
– And should be supplemented
– with extra doses of steroids perioperatively to avoid an
Addisonian crisis.

37. Coagulation disorders
■ Thrombophilia
– Patients with a strong family history or
– previous personal history of thrombosis should be identified
– POPs should be continued,
– HRT should be stopped 6 weeks prior to surgery
– antiplatelet agents should be withdrawn (7 days for aspirin, 10 days
for clopidogrel)
– If high risk of bleeding, aspirin alone should be continued

38. ■ High-risk patients with a history of
– recurrent DVT,
– pulmonary embolism (PE) and
– arterial thrombosis
■ will be on warfarin
■ This should be stopped before surgery and replaced by
■ LMWH (stopped 24hrs prior to surgery)
■ or factor Xa inhibitors

39. ■ For safer surgeries, preoperative INR should be below 1.5
■ Those with INR between 2.0-3.0, require witholding of medications
for 5 days preoperatively
■ UFH should be stopped 24 hrs prior to surgery
■ In emergencies, where anticoagulation cannot be reversed before
surgery, FFP must be administered
■ Oral Vit K can also be administered but takes 8hrs for effective
action

40. Neurological and psychiatric
disorders
■ Anticonvulsant and antiparkinson medication is continued
perioperatively to help early mobilisation of the patient
■ Lithium should be stopped 24 hours prior to surgery
■ Blood levels should be measured to exclude toxicity

41. ■ Anaesthetist should be informed well in advance if patient is on
anti-psychotics and MAO-inhibitors
■ As these medications interact with the anaesthetics administered
■ H/o seizure disorder or other significant CNS disorder like multiple
sclerosis
■ H/o myopathy or other muscle disorders should be recorded

42. Musculoskeletal and other disorders
■ Rheumatoid arthritis
– unstable cervical spine with the possibility of spinal cord injury during
intubation
– flexion and extension lateral cervical spine x-rays should be obtained
■ Ankylosing spondylitis
– techniques of spinal or epidural anesthesia are often challenging

43. ■ Systemic lupus erythematosus
– may exhibit a hypercoagulable state along with airway
difficulties
■ Other disorders like:
– Kyphosis or scoliosis cause functional compromise
– Temporomandibular joint disorders
– Cervical or thoracic spine injuries
– Patients receiving chemotherapy should be recorded

44. Airway assessment
■ Samsoon and Young modified Mallampati test
– Fauces, pillars, soft palate and uvula seen -----------
Grade 1
– Fauces, soft palate with some part of uvula seen -----------
Grade 2
– Soft palate seen -----------
Grade 3
– Hard palate only seen -----------
Grade 4

45. Preoperative checklist
■ Pre operative evaluation concludes with a review of all studies and
information obtained from investigative tests.
■ Informed consent after discussion with the patient and family
members is documented
■ Preoperative orders are written and reviewed

46. ■ Appropriate antibiotic prophylaxis depending on the type and site
of surgery
■ Antibiotic is administered within 60mins of surgical incision
■ 120 mins for vancomycin and fluoroquinolones
■ Repeat dosing is done usually at 3hrs for long abdominal
procedures
■ Careful review of the patients home medication is done (including
psychiatric drugs, hormones, and herbal medicines with dosages
and frequency)

47. ■ Preoperative shower with chlorhexidine the night prior
■ Preoperative fasting –
– Standard order of NPO past midnight in order to minimise aspiration
of stomach contents
■ Part preparation of the local area by clipping the hairs
■ Xylocaine sensitivity testing
■ Mechanical bowel preparation for abdominal surgeries
■ Anti-anxiety medications on the night before procedure if indicated

48. THANK YOU