1. Pre-anesthetic evaluation involves assessing the patient's medical history and conducting a physical exam to optimize the patient for anesthesia and surgery and reduce risks. 2. The evaluation identifies comorbidities, medications, and functional status to ensure safe anesthesia delivery and predict postoperative needs. 3. Relevant lab tests may be ordered depending on patient history to further evaluate organ function and bleeding risks.

1. Dr. Ankita Patil
Lecturer Anaesthesiology department
B.J Medical college Pune
Dr. Neharica Seth JR2

2. Anesthesia (from Greek an “without” aesthesis
“sensation”)The components of the anesthetic state
include
• unconsciousness • loss of memory • lack of pain •
immobility and attenuation of autonomic responses to
noxious stimulation.

3. Pre Anaesthetic Evaluation
• Defnition
The process of clinical assessment that precedes the delivery of
anesthesia care for surgery and for non-surgical procedures.
• Preoperative evaluation is an integral component of the
anesthesiologists’ role as perioperative physicians who are involved in
integrated medical care before, during, and after surgery

4. Goals and Benefits of PAC
• To ensure that the patient can safely tolerate anesthesia for the planned surgery.
• Mitigate perioperative risks
• Better document comorbid illness
• Reduce the patient’s (and family’s) anxiety through education
• Optimize preexisting medical conditions
• Order specialized investigations
• Initiate interventions intended to decrease risk
• To discuss aspects of perioperative care (e.g.anticipated risks, fasting guidelines),
• To arrange appropriate levels of postoperative care
• To predict the difficulty during intubation
• To obtain informed consent

5. Clinical examination
1. Medical History
2. Physical examination
Medical history
 Planned surgery and its indication
 Current known medical problems and past medical issues
 Diseases or symptoms their associated severity, stability, associated
activity limitations, exacerbations (current or recent), prior treatments, and planned
interventions
 Previous surgeries, anesthesia types, and anesthesia-related complications
 Prescription and over-the-counter medications should be documented, along with
their dosages and schedules

6.  any allergies to medications and other substances
Addictions-tobacco,alcohol,drugs consumption
smoking history
Pack year :No. cigarettes smoked per day x years smoked /20
20 pack years is considered as a significant factor for developing COPD
Family history: personal or family history of pseudocholinesterase deficiency and
malignant hyperthermia (including a suggestive history such as hyperthermia or
rigidity during anesthesia) must be clearly documented to facilitate appropriate planning
before the day of surgery. Information from previous anesthetic records may clarify an
uncertain history
Menstrual history: LMP

7. ASSESSMENT OF FUNCTIONAL CAPACITY
• Assessment of the patient’s cardiopulmonary fitness or functional capacity is an
integral component of the preoperative clinical examination
• Functional capacity is typically quantified in using the metabolic equivalent of task
(MET)
• One metabolic equivalent of task (MET) is the amount of oxygen consumed while
sitting at rest, and is equivalent to an oxygen consumption of 3.5 mL/min/kg body
weight.
• Value :- 1 – 12
(Light – Moderate – Vigorous)

9. Dukes activity status index
• 1-4 METS ( eating,dressing ,walking around the house,dish washing)
• 5-9METS ( Climb a flight of stairs ,walk one or 2 blocks on level ground,run a short
distance,moderate activites like golf,dancing )
• >10 METS ( sternous sports (swimming ,bicycle,tennis),heavy professional
domestic work

10. PHYSICAL EXAMINATION
GPE – Weight,Height, BMI
Higher mental function
Built
Nutritional Status
Nails :Cyanosis, Clubbing
Conjunctiva
Sclera ( Jaundice)
Back & Spine
Edema
Gait
Vital Signs – BP
Pulse
RR
Temperature

11. Airway examination
Pt is asked about:-
• Artificial Dentures
If yes it must be either removed / protected during the course of anesthesia
• Teeth ( Loose, Cracked, Chipped, Capped)
• Mouth opening
• Jaw Joint ( if it clicks, pops or hurts)
Maybe TM joint syndrome accompanied by chronic pain / repeated dislocation of
jaw.
• Snoring (Predictor of difficult intubation)
• Day time sleep (Somnolence) ( Sleep Apnea)

13. MALLAMPATI CLASSIFICATION
• Class I: soft palate, tonsillar fauces,
tonsillar pillars, and tip of uvula
visualized
• Class II: soft palate, tonsillar fauces,
and uvula visualized
• Class III: soft palate and base of uvula
visualized
• Class IV: only hard palate visualized
Class III and IV→ Difficult to
Intubate

14. DIFFICULT MASK VENTILATION
Predictors
• Age more than 55 years,
• BMI more than 26 kg/m2
• Absence of teeth
• Presence of a beard
• History of snoring
Others
• increased neck circumference
• face and neck deformities (i.e., prior surgery, prior radiation, prior trauma, congenital abnormalities)
• Rheumatoid arthritis-cervical spine is often affected-atlanto axial instability
• Trisomy 21 (Down syndrome)-microstomia,macroglossia,atlanto axial instability and sublaxation
• scleroderma -autoimmune condition causing fibrosis of skin-contractures may be
seen,microstomia,mandibular bone resorption -difficult intubation and difficul vascular assess
• cervical spine disease, or previous cervical spine surgery

16. Risk Factors for Postoperative Pulmonary Complications

17. Cardiovascular system
• We need to check that the pt is having any the
following conditions or not : CHF
HTN
IHD
Cardiomyopathy
Valvular / Subvalvular ds
Arrhythmias
Atherosclerosis
• To assess CVS: the pt is asked about
-- Shortness of breath(at rest,sleep)
-- chest pain, chest tightness
-- Pedal edema
-- Previous Heart / Lung surgery
-- medication

18. Hypertension
• Blood pressure > 140/90 mmHg
• Measurement should be >2 times on different occasion
• Should be taken in both arms
• The goals of preoperative evaluation are to identify any secondary causes of
hypertension, presence of other cardiovascular risk factors (e.g., smoking,
diabetes mellitus), and evidence of end-organ damage.
• The physical examination should focus on vital signs, thyroid gland, peripheral
pulses, and cardiovascular system (including bruits and signs of intravascular
volume overload).
• Cancellation/ postpone case if BP > 180/110 mmHg
• Stop ACE inhibitor and ARBs and continue beta blocker and clonidine

19. NYHA CLASSIFICATION
• NYHA class I: no limitation of physical activity; ordinary activity not a
cause of fatigue, palpitations, or syncope
• NYHA class II: slight limitation of physical activity; ordinary activity
resulting in fatigue, palpitations, or syncope
• NYHA class III: marked limitation of physical activity; less than ordinary
activity resulting in fatigue, palpita_x0002_tions, or syncope; comfort at
rest
• NYHA class IV: inability to do any physical activity without discomfort;
symptoms at rest

20. Renal system
• The preoperative evaluation of patients with CKD should emphasize the cardiovascular
system, cerebrovascular system, intravascular volume status, and electrolyte status.
• The early stages of CKD typically cause no symptoms.
• The anesthesiologist should inquire about the cardiovascular systems (i.e., chest pain,
orthopnea, paroxysmal nocturnal dyspnea), urine output, associated comorbidities,
medications, dialysis schedules, and any hemodialysis catheter problems (e.g., infection,
thrombosis).

21. Hepatic system
• Most of the patients with liver disease will be asymptomatic
• Some may complain Fatigue, weight loss, dark urine, pale stools, pruritus, right
upper quadrant pain, bloating, and jaundice
• Physical Examination : jaundice, bruising, ascites, pleural effusions, peripheral
edema, hepatomegaly, splenomegaly, and altered mental status
• Past history of liver disease should be asked

22. ENDOCRINE SYSTEM
Endocrine disturbances & end organ effects of -
DM
Thyroid/Parathyroid
Pituitary
Adrenals
Can increase perioperative risk substantially.
* Pt is asked about
--waking up at night freq to urinate (DM)
--increased thirst (DM)
--increased perspiration than others (Pheochromocytoma)
--Headache (Pheochromocytoma)
--Feeling more cold/warm (hypo/hyperthyroid)
--Muscle cramps/spasm in legs >3 times a year (Thyroid)

23. • Diabetes
• Blood Sugar
– Normal :-
Fasting :- 70-100 mg %
PP :- less than 126 mg %
– Diagnostic Criteria :-
Fasting :- > 125 mg % or
Glucose tolerance test > 200 mg % (2 hr.)
Random :- 200 mg % or more with symptoms ( polyurea, polydypsia, unexplained
wt.loss)
• usual glycemic control, history of hypoglycemic episodes, current therapy, and the
severity of any end-organ complications should be documented
• physical examination
– evaluation of pulses
– skin breakdown
– joint (especially cervical spine) mobility

24. NEUROLOGICAL SYSTEM
Pt is asked about
-- h/o seizure / convulsion / stroke/fall/
head injury/head surgery
-- pin & needle sensation in arms & legs
-- Migraine

25. MUSCULOSKELETAL SYSTEM
Pt is asked about
-- h/o arthritis
-- low back pain
-- taking pain pills/pain shots in last 6 months
Examination of Back & spine:
-- Done to evaluate any congenital deformity/ kyphoscoliosis etc.
-- to assess whether spines are fused or not.

26. HEMATOLOGICAL SYSTEM
Pt is asked about
-- problem with blood clotting if any after minor cuts / bruise
-- H/O spontaneous bleeding
-- H/O blood transfusion

27. INVESTIGATION
• COMPLETE BLOOD COUNT, HEMOGLOBIN, AND HEMATOCRIT
• Typical clinical indications include
– history of increased bleeding
– hematologic disorders
– CKD
– chronic liver disease,
– recent chemotherapy or radiation treatment
– corticosteroid therapy
– anticoagulant therapy
– poor nutritional status

28. Renal function test
• clinical indications include
– diabetes mellitus
– hypertension
– cardiac disease
– potential dehydration (e.g., vomiting, diarrhea)
– anorexia
– bulimia
– fluid overload states (e.g., heart rate, ascites)
– known renal disease, liver disease
– relevant recent chemotherapy (e.g., cisplatin, carboplatin)
– renal transplantation

29. LIVER FUNCTION TESTING
• clinical indications include
– a history of hepatitis (viral, alcohol, drug-induced, autoimmune)
– jaundice
– cirrhosis
– portal hypertension
– biliary disease
– gallbladder disease
– hepatotoxic drug exposure
– tumor involvement of the liver
– bleeding disorders

30. COAGULATION TESTING
• indications for testing
– include a known bleeding disorder
– hepatic disease
– anticoagulant use.

31. ELECTROCARDIOGRAM
• clinical indications include
– a history of IHD
– hypertension
– diabetes mellitus
– heart failure
– chest pain
– palpitations
– abnormal valvular murmurs
– peripheral edema
– syncope
– dizziness
– dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea,
– CVD

32. Chest XRAY
• clinical indications include
– advanced COPD
– bullous lung disease
– suspected pulmonary edema
– suspected pneumonia
– suspected mediastinal masses
– suspicious findings on physical examination (e.g., rales, tracheal deviation)

33. Special Consideration For Thyroid
• indirect laryngoscopy
• ENT check up for vocal cords
• Recent TFT
• Possibility of difficult intubation
• Pre op tracheostomy consent for possible tracheomalacia

34. American Society of Anesthesiologists Physical Status
Classification

35. NBM for the surgery

36. Preparation For Anesthesia
• Continuing Current Medications/ Treatment of Coexisting
Diseases
It is the RESPONSIBILITY of the anesthesiologist to instruct
patients regarding which medications to take and which to
hold preoperatively.

37. • Instruct Patients to take the medications with small sips of water,
even if fasting!
• Medications to be Continued on the day of Surgery
1. Antihypertensives except ACE Is and ARBs
2. Cardiac medications e.g ᵦ- blockers, digoxin
3. Antidepressants, anxiolytics and other psychiatric medications
4.Thyroid medications
5.Birth control pills, eye drops, heartburn or reflux medications,
narcotics, anticonvulsants, asthma medications, Steroids, Statins

38. • Aspirin
Consider selectively continuing aspirin in patients where the
risk of cardiac events is felt to exceed the risk of major
bleeding.
if reversal of platelet inhibition is necessary, stop aspirin at
least 3 days before surgery.
Do not discontinue aspirin if patients who have drug eluting
coronary stents until they have completed 12 months of
dual anti platelet therapy.

39. Thienopyridines (Clopidogrel and Ticlopidine)
• Patients having Cataract Surgery – Do not need to stop.
• If reversal of platelet inhibition is necessary, then
clopidogrel must be stopped 7 days before surgery
(Ticlopidine – 14 days)
• Do not discontinue Thienopyridines in Pt. who have drug
eluting stents before 1 year

40. Medications to be discontinued
• Topical medications e.g creams and ointments
• Oral hypoglycemic agents ( on the day of Sx)
• Diuretics (on the day of Sx except Thiazide)
• Sildenafil ( Viagra) of similar drugs – discontinue 24 hrs
before Sx.
• NSAIDS – discontinue 48 hrs before Sx.
• Warfarin ( Coumadin) discontinue 5 days before Sx

41. Pharmacological Agents to Reduce the risk of Pulmonary
Aspiration
• Histamine – 2 Receptor Antagonist : block the ability of histamine to induce
secretion of gastric fluid with high hydrogen concentrations e.g. Cimetidine,
Ranitidine, Famotidine
• Antacids – neutralize the acid in gastric contents
• Proton pump inhibitors: supress gastric acid secretion by binding proton pump
of the parietal cell
• Gastrokinetic Agents : Metoclopramide
• Dopamine antagonist.

42. Psychological Preparation
• Preoperative visit and interview with the patient and family
members,
• The anesthesiologist should explain anticipated events
and the proposed anesthetic management in an effort to
reduce anxiety and diminish apprehension.

43. Pharmacological preparation
• To relief anxiety and production of sedation
• Prevention of Autonomic reflexes mediated through the
vagus nerve.
• Prevention of nausea and vomiting.

44. • Benzodiazepines
Produces anxiolysis, amnesia and sedations e.g. Diazepam,
Midazolam, Lorazepam.
Diphenhydramine : histamine-1 receptor antagonist, blocks the
peripheral effects of histamine, it has sedative, anticholinergic and
antiemetic activity.
Anticholinergics : (Atropine, glycopyrolate)
1. Antisialogogue effect
2.sedation and amnesia
3. Vagolytic effect

45. Antibiotic Prophylaxis
• Cephalosporins are the most popular antibiotics because they
cover skin microbes,
• For intestinal Sx, anaerobic and Gram negative coverage is
needed.
• Antibiotics must be administered within 1 hr prior to incision
except : Vancomycin should be given 2hr prior to incision
• when tourniquet is used, the antibiotics should be adminstered
prior to its inflation.

46. Conclusion
• The anesthesiologist who takes the time to adequately
prepare the patient medically and psychologically for
anesthesia and surgery will find that their job of caring
for the patient intraoperative becomes easier, and they
are more likely to have a positive outcome as well as a
satisfied patient.