Pre-anesthetic evaluation

1. Preoperative Assessment,
Preparation And Documentation
Meron Abrar ( MSc Anesthetist)
Addis Ababa University, HSC,SOA
4/22/2021 1

2. Course Goal:-
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To equip the participants with the
knowledge, skill and attitude needed to
assess patients preoperatively, to
document, reporting and consultation
of referral.

3. Out line
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Introduction
Definition
Objectives of pre anesthetics assessment
Steps of pre anesthetics assessment
•History
•Physical examination
•ASA classification
•Air way assessment
•Investigations
Documentation on the Anesthesia Record
•Preanesthetics documentation
•Intraoperative anesthesia recordings
•Post operative orders and recordings

4. PREOPERATIVE ASSESSMENT
• Why preoperative assessment is important?
• How it should be done?
• By whom?
• What can be expected?
• The importance of test selection based on
patient’s needs on scientific evidence of
effectiveness.
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5. Introduction
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Anesthetic drugs and techniques have profound
effects on human physiology. Hence, a focused review
of all major organ systems should be completed prior to
surgery.
Goals of the preoperative evaluation is to ensure that
the patient is in the best (or optimal) condition.
Patients with unstable symptoms should be postponed
for optimization prior to elective surgery.

6. Definition
• Preanesthetic evaluation is evaluation
of the patients’ medical, physical and
mental status before you are taking
your patient to the operation theater.
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7. THE AIMS OF PREOPERATIVE ASSESSMENT
• The main aim of the preoperative visit is to assess the
patient’s fitness for anesthesia.
• It is performed by an anesthetist, preferably the one
who is going to administer the anesthetics.
• All patients would be seen by their anesthetist
sufficiently ahead of the planned surgery to allow any
problems identified to be treated without interfering
with the smooth running of the operating list.
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8. THE AIMS OF PREOPERATIVE ASSESSMENT
• To reduce the risks associated with surgery and
anesthesia.
• To increase the quality (thus decreasing the cost)
of preoperative care.
• To restore the patient to the desired level of
function.
• To obtain the patients’ informed consent for the
anesthetics procedure.
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9. THE PREOPERATIVE VISIT cont….
• The visit allows the most suitable anaesthetic
technique to be determined.
• To determine any potential interactions between
concurrent disease and anaesthesia to be
anticipated.
• To provide an explaination and reassurance for the
patient.
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10. THE PREOPERATIVE VISIT cont…
• Where there is co-existing illness, every opportunity
must be taken to improve the patient’s condition
prior to surgery.
• This may mean seeking advice from other specialists
to optimize treatment, although the final decision
will rest with the anesthetist.
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11. SPECIAL ARRANGEMENTS
Three situations:
1. Patients with complex medical or
surgical problems;
- The patient is often admitted several days prior to
surgery.
- The anesthetists is actively involved
in optimizing their condition prior to
anaesthesia and surgery.
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12. SPECIAL ARRANGEMENT cont...
2. Surgical emergencies;
- The anesthetist must be informed as soon as the
decision to operate has been made and advice sought
about the need for urgent investigations or treatment.
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13. SPECIAL ARRANGEMENT cont…
3. Day-case patients;
- Anesthetic assessment is often carried out by the
surgeon or a designated clinic nurse according to
protocol, and the patient’s first contact with the
anaesthetist is on arrival in the day-case unit.
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14. Source of information
• Chart
• Old Medical Records
• Patient - Family
• Physician - Surgeon
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15. I. Problem Identification
II. Risk Assessment
III. Preoperative Preparation
IV. Plan of Anesthetic Technique
Steps of the preoperative visit :
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16. Steps of the preoperative visit :
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17. Scope of Preoperative
Evaluation
• History
• Physical examination
• Laboratory studies
• Anesthetic note
• Guideline for NPO status
• Premedication
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18. History
• History in general
• History of coexisting medical illnesses
• History of taking medicine
• History of allergies and drug reactions
• Anesthetic history
• Family History
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19. History in general
• Patient interview
• Review medical record
• Direct discussion with the medical staff and
surgical staff
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20. I. Problem Identification
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Medical History (Review of Systems)

21. I. Problem Identification
• Cardiovascular : hypertension ; ischemic , valvular or
congenital heart disease; CHF or cardiomyopathy, , arrhythmias
• Respiratory : smoking; COPD; restrictive lung disease; altered
control of breathing (obstructive sleep apnea, CNS disorders, etc.)
• Neuromuscular : raised ICP ; seizures; spinal cord Injury;
disorders of NM junction e.g myasthenia gravis, muscular dystrophies
,MH
• Endocrlne : DM; thyroid disease; pheochromocytoma; steroid
therapy
• GI - Hepatic : hepatic disease; gastresophageal reflux
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Medical history (Review of Systems) cont…
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22. I. Problem Identification
• Renal : renal failure
• Hematologic : anemia; coagulopathies
• Elderly , Children, Pregnancy
• Medications and Allergies
• Prior Anesthetics
• Related to Surgery : significant blood loss; respiratory
compromise; positioning
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Medical history (Review of Systems) cont…
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23. ANAESTHETIC HISTORY AND EXAMINATION
The anesthetist should take a full history and examine
each patient.
• Previous anaesthetics and operations;
- The patient should be asked if they suffer from any
Inherited or ‘family’ diseases or
whether they have experienced any difficulties
with previous anaesthetics
e.g., nausea, vomiting.
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24. ANAESTHETIC HISTORY …
• The records of previous anesthetics must be
checked to rule out or clarify problems such
as
 difficulties with intubation,
drugs administered or adverse
reactions.
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25. Previous anesthetic record
• Response to Sedative/Analgesic
• Premedication and Anesthetic Agents
• Endotracheal Tube Size
• Preanesthetic Complications
• Postoperative Complications
• difficulties with intubation,
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26. ANAESTHETIC HISTORY AND EXAMINATION
- The approximate date of previous anesthetics,
particularly if recent, should be identified to avoid
the risk of repeat exposure to halothane.
- Details of previous surgery may reveal potential
anesthetic problems,
for e.g., cardiac or pulmonary surgery.
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27. 2. ANAESTHETIC HISTORY AND EXAMINATION
cont……
• Family history;
- Any family members had experienced problems with
anesthesia or whether there are any known inherited conditions
in the family e.g.
 Prolonged apnea
An unexplained death
Malignant hyperpyrexia
 Hemophilia
Sickle-cell disease.
o Surgery should be postponed if any of these conditions are
identified and the patient investigated appropriately.
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28. ANAESTHETIC HISTORY AND EXAMINATION
cont……
• Drug history and allergies;
- All medications, both prescribed and self
administered, should be identified preoperatively.
- Previous medications should be identified,
especially if there was any adverse reaction.
- Allergies to drugs, topical preparations (e.g.
iodine), adhesive dressings and foodstuffs should
be noted.
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29. Drug history and allergies
• Antihypertensive
• Antiarrhythmic
• Anticoagulant
• Anticonvulsant
• Specific Endocrine- Insulin,
- Antithyroid Drug /PTU, Tyroxin/
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30. Drug history and allergies
• Antibiotics
– sulfonamide
– penicillin
– cephalosporin derivatives
• Allergy to shellfish or seafood
• IV contrast dye
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31. Drug history and allergies
• True allergic reactions
 skin manifestations (pruritus with
flushing)
 face or oral swelling
shortness of breath
Wheezing
 vascular collapse
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32. 2. ANAESTHETIC HISTORY AND EXAMINATION
cont……
• Social history;
1. Smoking
Ascertain
how long the patient has been smoking &
what their consumptions of cigarettes or grams of tobacco
per day.
The adverse effects include:
 a reduced oxygen carriage due to raised
carboxyhaemoglobin levels
 tachycardia,
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33. 2. ANAESTHETIC HISTORY AND EXAMINATION
cont……
 hypertension and
 coronary artery narrowing caused by nicotine
stimulating the sympathetic nervous system.
 Smokers have a significant increase in
 Postoperative chest infections,
 Chronic lung disease and
 carcinoma.
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34. 2. ANAESTHETIC HISTORY AND EXAMINATION
cont……
Stop smoking for:
- eight weeks improves the airways
- two weeks reduces their irritability
- as little as 24 hours prior to anesthesia decreases
carboxy hemoglobin levels.
2. Alcohol
This is best measured as units consumed per week.
Excessive consumption (>50 units/week) causes
 Induction of liver enzymes and tolerance to
anesthetic drugs.
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35. 2. ANAESTHETIC HISTORY AND EXAMINATION
3. Drugs
Ask specifically about the use of drugs for recreational
purposes including; type, frequency and route of
administration.
4. Pregnancy
The date of the last menstrual period should be noted in all
women of child-bearing age. Anaesthesia increases the risk
of inducing a spontaneous abortion in early pregnancy.
There is an increased risk of regurgitation and aspiration in
late pregnancy. Elective surgery is best postponed until
after delivery.
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36. Physical examination
• Special attention to the evaluation of the
 vital signs
 heart(CVS)
Lung
 abdomen and
 neurologic examination
airway
• If regional anesthesia is proposed : detailed
assessment of the back(Anatomical status of
vertebral spine)
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37. Vital signs
• Blood pressure
• Resting pulse
• rate, rhythm, and fullness
• Respiration
• -rate, depth, and pattern at rest
• Body temperature
• Pain score (baseline score)
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38. Physical examination
• The examination
 As with the history that is taken, the examination
concentrates on the cardiovascular and respiratory systems.
 Attention must also be paid to the airway, in order to try and
identify those patients in whom there may be potential
problems.
 The remaining systems are examined if problems relevant to
anesthesia are identified.
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39. Physical examination
1. Cardiovascular system
Determine whether there are any arrhythmias, for e.g.,
atrial fibrillation, and look for signs of heart failure.
The patient’s blood pressure should be taken and
compared with that recorded by the nursing staff.
The peripheral veins should be inspected to identify any
potential problems with intravenous access.
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40. Physical examination
cont……
2. Respiratory system
Look for
cyanosis,
the pattern of ventilation
 count the respiratory rate
Dyspnea may be present at rest
Wheeziness
signs of collapse
consolidation and
effusion should be identified.
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41. Physical examination
cont……
3. Nervous system
• Chronic disease of the peripheral and central nervous
systems should be identified
• Any evidence of motor or sensory impairment recorded
e.g., myotonica, multiple sclerosis.
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42. Abdominal exam (GI-Hepatic)
• Patients with hepatic disease frequently present
problems with fluid and electrolyte imbalance.
• Coagulopathies and altered drug metabolism.
• Patients with gastro esophageal reflux (GER), as
well as those at risk for GER, are prone
• Regurgitation of gastric contents
• Aspiration pneumonitis during the perioperative period
• Rapid Sequence Induction & Unusual Anaesthetic
Complications – Aspiration Pneumonitis).
• These patients should receive anti-reflux
prophylaxis preoperatively.
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43. Physical examination
cont……
4. Musculoskeletal
 Patients with connective tissue disorders should have any
restriction of movement and deformities noted.
 Patients suffering from chronic rheumatoid disease frequently
have
a reduced muscle mass
peripheral neuropathies and
pulmonary involvement.
 Particular attention should be paid to the patient’s cervical
spine and temporomandibular joints.
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44. 5. The airway
At the preoperative visit, all patients must
have an assessment made of their airway,
irrespective of the technique planned for
airway maintenance during anesthesia.
The main objective is to try and predict those
patients in whom there may be difficulty with
intubation.
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45. Airway assessment
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46. Physical examination- airway exam…
Assessment is often made in three stages;
- Observation of the patient’s anatomy – any limitation
of mouth opening, a receding mandible, health of
teeth etc..
- Simple bedside tests – Wilson score, Mallampati
criteria, Thyromental distance.
- X-rays; measurements made on the lateral
x-ray of the head and neck.
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47. Skull (Hydro and Microcephalus)
Teeth (Buck, protruded, & loose teeth. Macro and Micro mandibles)
Obstruction (obesity, short Bull Neck & swellings around the head and
neck)
Pathology (Craniofacial abnormalities & Syndromes e.g. Treacher Collins,
Goldenhar's, Pierre Robin syndromes)
“Patients with an abnormal airway (including Class III or IV
airway) should be considered at higher risk “.
Malformation of the skull
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48. Tumor
of oral
cavity
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1- Observation of the patient’s anatomy
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49. 1- Observation of the patient’s anatomy
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50. 4/22/2021 50
Treacher Collins
(mandibulofacial dysostosis)
1- Observation of the patient’s anatomy

51. Pierre Robin
( hypertelorism; and external and middle ear deformities)
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52. 4/22/2021 52
1- Observation of the patient’s anatomy

53. Predictors of difficult intubation ( 4 M )
Mallampati
Measurements 3-3-2-1 or 1-2-3-3 Patient ‘s fingers
Movement of the Neck
Malformations of the Skull
Teeth , Obstruction & Pathology
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2- Simple bedside tests
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54. Class I = visualize the soft palate, fauces, uvula,
anterior and posterior pillars.
Class II = visualize the soft palate, fauces and
uvula.
Class III = visualize the soft palate and the base
of the uvula.
Class IV = soft palate is not visible at all.
Mallampati
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55. Measurements 3-3-2-1
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3 Fingers Mouth Opening
3 Fingers Hypomental Distance. (3 Fingers between the tip
of the jaw and the beginning of the neck (under the chin)
2 Fingers between the thyroid notch and the floor of the mandible
(top of the neck)
1 Finger Lower Jaw Anterior sublaxation

56. Movement of the Neck
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57. Wilson Risk Test
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58. Interincisor gap
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59. Thyromental distance – “A”
> 6.0 cm lower risk group
< 6.0 cm higher risk group
Sternomental distance –
“B”
> 12.5 cm lower risk
< 12.5 cm higher risk
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The measurements are
taken with the head and
neck fully extended

60. Thyromental distance
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61. temporomandibular joint
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62. II. Risk Assessment
Components for evaluating perioperative risk:
• patient's medical condition preoperatively
• extent of the surgical procedure
• risk from the anesthetic
“Most of the work, however, addresses the
operative risk according to the patient's
preoperative medical status”
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63. medical status mortality
ASA I normal healthy patient without organic, biochemical,
or psychiatric disease
0.06-0.08%
ASA II mild systemic disease with no significant impact on
daily activity e.g. mild diabetes, controlled
hypertension, obesity .
Unlikely to have
an impact
0.27-0.4%
ASA III severe systemic disease that limits activity e.g. angina,
COPD, prior myocardial infarction
Probable impact
1.8-4.3%
ASA IV an incapacitating disease that is a constant threat to
life e.g. CHF, unstable angina, renal failure ,acute MI,
respiratory failure requiring mechanical ventilation
Major impact
7.8-23%
ASA V moribund patient not expected to survive 24 hours e.g.
ruptured aneurysm
9.4-51%
ASA VI brain-dead patient whose organs are being harvested
ASA Physical Status Classification System
For emergent operations, you have to add the letter ‘E’after the classification.
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64. Preoperative Laboratory Testing:
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only if indicated from the preoperative history and physical
examination.
"Routine or standing" pre operative tests should be discouraged
-CBC anticipated significant blood loss, suspected hematological disorder
(eg. anemia, thalassemia, SCD), or recent chemotherapy.
-Electrolytes diuretics, chemotherapy, renal or adrenal disorders
-ECG age >50 yrs ,history of cardiac disease, hypertension, peripheral
vascular disease, DM, renal, thyroid or metabolic disease.
-Chest X-rays prior cardiothoracic procedures ,COPD, asthma, a change in
respiratory symptoms in the past six months.
-Urine analysis DM, renal disease or recent UTI.
-tests for different systems according to history and examination

65. III. Preoperative Preparation
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• Anesthetic indications:
-Anxiolysis, sedation and amnesia. e.g. benzodiazepine (diazepam , lorazepam)
-Analgesia e.g. narcotics
-Drying of airway secretions e.g. atropine, glycopyrrolate, scopolamine
-Reduction of anesthetic requirements ,Facilitation of smooth induction
-Patients at risk for GE reflux :ranitidine ,metoclopramide , sodium citrate
• Surgical indications:
-Antibiotic prophylaxis for infective endocarditis.
-Prophylaxis against DVT for high risk patients : low-dose heparin or aspirin
intermittent calf compression, or warfarin.
• Co-existing Disease indications:
Some medications should be continued on the day of surgery e.g. B blockers, thyroxine.
Others are stopped e.g. oral hypoglycemics and antidepressants .
Steroids within the last six months may require supplemental steroids

66. MEDICATION ADMINISTRATION ROUTE DOSE (mg)
Lorazepam Oral, IV 0.5–4
Midazolam IV Titration of 1.0–2.5-mg doses
Fentanyl IV Titration of 25–100–µg doses
Morphine IV Titration of 1.0–2.5-mg doses
Meperidine IV Titration of 10–25-mg doses
Cimetidine Oral, IV 150–300
Ranitidine Oral 50–200
Metoclopramide IV 5–10
Atropine IV 0.3–0.4
Glycopyrrolate IV 0.1–0.2
Scopolamine IV 0.1–0.4
Common Preoperative Medications, Doses, and
Administration Routes (adult)
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67. INGESTED MATERIAL
MINIMUM FASTING PERIOD,
APPLIED TO ALL AGES (hr)
Clear liquids 2
Breast milk 4
Infant formula 6
Nonhuman milk 6
Light meal (toast and clear liquids) 6
Fasting Recommendations
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68. IV. Plan of Anesthetic Technique
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1. Is the patient's condition optimal?
2. Are there any problems which require consultation or special tests?
“Please assess and advise “
3. Is there an alternative procedure which may be more appropriate?
4. What are the plans for postoperative management of the patient?
5. What premedication if any is appropriate?

69. Informed Consent
• Anesthesia options
• Anesthesia procedures
• Anesthesia risks
• Questions
• Consent
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70. Patient Assessment
• Pre-Anesthesia Instructions
• Pre-Anesthesia Orders
• Medicine/Cardiac Consults
• Pre-Anesthesia Record
• Anesthesia Consent
• Progress Note
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71. 2. Documentation on the
Anesthesia Record
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72. 2. Documentation on the Anesthesia Record
• Recording information on the anesthesia record is
important.
• The anesthesia provider is responsible for the patient
from the time they enter the operating room through
the recovery period.
• Maintaining a continuous record will help the
anesthesia provider remain vigilant during the case.
• A well documented anesthesia record is useful for
future anesthetics, guiding care of the patient.
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73. 2. Documentation on the Anesthesia Record
• It serves to document anesthetic technique and
complications that may have been encountered
during the anesthetic.
• Documentation should be neat and legible.
• Anesthesia records differ from practice to
practice.
• Documentation should include.
– Pre-anesthesia Evaluation Documentation
– Anesthesia Care Documentation
– Post operative order
• Look at full sized anesthesia record that may be
copied and freely used. (look at on page 25)
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74. a. Pre-anesthesia Evaluation
Documentation
• The first item that should be documented is
identification of the patient. This will ensure that
the preanesthesia workup does not get confused
with another patient.
• The date of surgery, patient name, proposed
surgical procedure, name of the surgeon, family
contact, name of the anesthesia provider, city or
village, ward or bed number, height, weight, and
pre-operative vital signs should be
documented.(page 16)
• Review the patient’s laboratory values and
document the results. (page 17)
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75. a. Pre-anesthesia Evaluation
Documentation
• Review diagnostic studies including electrocardiograms
(ECG) or chest x-rays (CXR) and document the results.
• The next step involves the patient interview and a
physical exam.
• The interview consists of a systemic inquiry concerning
the patient’s health history .
• The physical exam & findings.
• ASA classification of the patient.
• Air way assessment findings.
• Document the anesthetic plan.
• Document preparations prior to the administration of
an anesthetic are essential to good and safe care( page
27)
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76. 76
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77. anaesthesia safety checks before any anesthetic
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78. b. Anesthesia Care Documentation
• Document the date and ASA classification,Start
the IV, documenting the site and size of the IV
,catheter.
• If the patient received premedication, document
the medication, dose, and route.
• Apply monitors to the patient and record an
initial set of vital signs.
• Document the ECG rhythm, heart rate, blood
pressure, and pulse oximetry reading.
• Document the monitors that will be used during
the case.
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79. b. Anesthesia Care Documentation
• Document the intravenous fluid type and the
amount infused. Document the medications
that you will administer during the anesthetic.
• The section of the anesthesia record called
“Remarks” is provided for documentation of
the anesthesia provider’s actions, unusual
events, or problems encountered. If the
patient is receiving a general anesthetic,
document the type of circuit being used.
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80. b. Anesthesia Care Documentation
• Document that
• the patient has been pre-oxygenated;
• the type of induction (intravenous, inhaled, or
intramuscular injection);
• use of mask ventilation,
• laryngeal mask airway, or endotracheal tube;
• cricoid pressure;
• type of intubation (nasal or oral); size of endotracheal
tube; size of laryngoscope blade; type of laryngoscope
blade; any difficulties encountered during intubation;
and presence of equal, bilateral lung sounds.
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81. b. Anesthesia Care Documentation
• Document that the patient’s eyes are protected.
• Document the positioning and ensure pressure points
have been padded.
• If the patient receives a regional anesthetic, document
the type of regional block; position of the patient;
interspace used for spinal or epidural anesthesia;
needle type; needle size; the presence of paresthesia’s.
• the presence of cerebral spinal fluid for spinal
anesthesia; type of local anesthetic used; dose; volume
of local anesthetic; preparation solution; and the level
of block.
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82. b. Anesthesia Care Documentation
• Document supplemental O2 administered by mask or
nasal cannula.
• All medications and dosages should be recorded. The
type of ventilation should be documented as
spontaneous, assisted, or controlled. This can be
indicated by a “S” for spontaneous, “C” for controlled,
and “A” for assisted.
• The patient’s vital signs, pulse oximetry, and other
monitors should be documented every five minutes.
• Your completed anesthesia record should be similar to
the following example.
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83. 83
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84. 84
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85. b. Anesthesia Care Documentation
• At the end of the anesthetic, document the
total amount of medications administered, IV
fluids,blood or blood products administered,
blood loss, and urine output. Document the
initial vital signs in the recovery area.
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86. Summery
Definition
Objectives of pre anesthetics assessment
Steps of pre anesthetics assessment
• History
• Physical examination
• ASA classification
• Air way assessment
• Investigations
Documentation on the Anesthesia Record
• Preanesthetics documentation
• Intraoperative anesthesia recordings
• Post operative orders and recordings 86
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87. References
87
Safe anesthesia –third edition, Lucille Bartholomeusz and Jean Lees 2006
Basic guide to anesthesia for developing countries, Daniel D. Moos,
 http://www.worldanaesthesia.org,
Basics of anesthesia, Sixth edition, 2011, Ronald D Miller and Manuel C
Pardo, Jr
Clinical Anesthesiology, 4th Edition, G. Edward Morgan, Jr., Maged S.
Mikhail, Michael J. Murray
Clinical Anesthesia, 6th Edition by Barash, Paul G.; Cullen, Bruce F.;
Stoelting, Robert K. 2010
Miller’s Anesthesia, 7th edition by Ronald D. Miller, 2010
Standards for infusion therapy, Royal College of nursing, Third edition,
January 2010
WHO Guidelines for Safe surgery:2009
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88. Peripheral Brain
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