For surgical residents presentation

1. By
Dr olofin K.E
Anaesthetic Unit
Asokoro District Hospital

2. Outline
Introduction
Definition
Aims
Preanesthetic evaluation
Preanesthetic planning
Premedication and other prophylactic measures
Prediction of perioperative morbidity or mortality
Conclusion
References

3. Introduction
 All patients scheduled to undergo surgery should be
assessed in advance with a view to planning optimal
preparation and perioperative management.
 It is one mechanism by which the standard and
quality of care provided by the anaesthetist is
measured.

4. Definition
 Preanesthetic evaluation is a medical check-up and
laboratory investigations done by the anaesthesiologist
before an operation, to assess the patient's physical
condition and any other co-morbidities.

5. Aims
 To create rapport with the patient
 To ensure history, physical examination and proper
investigation optimise patient for anaesthesia.
 To confirm that the surgery proposed is realistic and
beneficial to the patient and the possible risks
involved.
 To anticipate potential problems and adequately plan
for them

6. Preanesthetic assessment
History
 Bio data: Age, gender
 Indication for surgery
 Surgical/Anaesthetic Hx: previous anaesthesia, surgery
and complications
 PMHx
hypertension, diabetes, asthma, sickle cell disease etc

7. Preanesthetic assessment
 Drug Hx. Medications, drug allergies,
 F/SHx: Cigarette smoking, alcohol consumption, use
of recreational drugs

8. Preanesthetic assessment
General examination
• General assessment of nutrition and mental status
Systemic examination
• CNS, CVS, and respiratory systems

9. Preanesthetic assessment
Airway assessment
It is done to determine intubation difficulty (no single
test is 100% specific or sensitive)
Relative to tongue/pharyngeal size using the
mallampatti classification.

10. Preanesthetic assessment
Mallampati classification
• Class I : Visualization of the
soft palate, fauces; uvula,
anterior and the posterior
pillars.
• Class II : Visualization of the
soft palate, fauces and uvula.
• Class III : Visualization of
soft palate and base of uvula.
• Class IV: Only hard palate is
visible. Soft palate is not
visible at all.

13. Preanesthetic assessment
Atlanto occipital joint (AO) extension
• Grade I : >35°
• Grade II : 22°-34°
• Grade III : 12°-21°
• Grade IV : < 12°
• Normal angle of extension is 35° or more

14. Preanesthetic assessment

15. Preanesthetic assessment
"3-3-2 rule"
A. Inter-incisor distance- (<3
finger breadths is associated
with difficulty in intubation)
B. Š
Hyomental distance (distance
of lower mandible in midline
from the mentum to the hyoid
bone); <3 finger breadths (<6
cm) is associated with difficult
intubation
C. Š
Thyrohyoid distance (<2
finger breadths is associated
with difficult intubation)

18. Preanesthetic assessment
LEMON airway assessment method
 The score with a maximum of 10 points is calculated by
assigning 1 point for each of the following LEMON
criteria:

19. Preanesthetic assessment
 L = Look externally (facial trauma, large incisors, beard
or moustache, large tongue)
 E = Evaluate the 3-3-2 rule
 M = Mallampati (Mallampati score > 3).
 O = Obstruction (presence of any condition like
epiglottitis, peritonsillar abscess, trauma).
 N = Neck mobility (limited neck mobility)

20. Preanesthetic assessment
Others
• Š
Anterior jaw subluxation (<1 finger breadth is
associated with difficult intubation)
• ƒ
Tongue size dentition, dental appliances/prosthetic
caps, existing chipped/loose teeth – must inform
patients of rare possibility of damage
• ƒ
Nasal passage patency (if planning nasotracheal
intubation)

21. Preanesthetic assessment
 examination of anatomical sites relevant to lines and
blocks
 ƒ
bony landmarks and suitability of anatomy for
regional anaesthesia (if relevant)
 ƒ
sites for IV, central venous pressure (CVP), and
pulmonary artery (PA) catheters

22. Preanesthetic assessment
Investigations
 FBC,Urinalysis, Urea, creatinine and electrolytes Blood
glucose, Liver function tests, Coagulation screen, ECG,
Chest X-ray
 Others: Echocardiography, Pulmonary Function Tests,
Cardiopulmonary Exercise Testing

23. Preanesthetic preparation
Having taken
 Full clinical history,
 Physical examination
 Reviewed the relevant investigations,
 Satisfied?
 Go ahead with surgery or reschedule

24. Preanesthetic preparation
 Preoperative fasting
 providing information to the patient and obtaining
consent to proceed
 Ensuring blood products are available during the
perioperative period if necessary
 organizing appropriate staff and equipment within the
operating theatre suite.
 Reschedule Surgery for Clinical Reasons

25. Preanesthetic preparation
Reasons include
 Acute upper respiratory tract infection
 Coexisting medical disease and drug therapy,
 Emergency surgery for which the patient has not been
resuscitated adequately
 Recent ingestion of food
 Failure to obtain consent

26. Premedication and other prophylactic
measures
Premedication refers to the administration of drugs in
the period 1–2 h before induction of anaesthesia.
Aim:
 allay anxiety and fear
 reduce postoperative nausea and vomiting
 assist with intra- and postoperative analgesia
 reduce secretions

27. Premedication and other
prophylactic measures
 reduce the volume and increase the pH of gastric
contents
 attenuate vagal reflexes
 attenuate sympathoadrenal responses.

28. Premedication and other
prophylactic measures
Pre-anesthetic medications to stop
 ƒ
oral antihyperglycemics: stop on morning of surgery
 ƒ
antidepressants: stop on morning of surgery
 ƒ
ACE inhibitors and angiotension receptor blockers: may
stop on morning of surgery (controversial)
 ƒ
anticoagulants

29. Prediction of perioperative morbidity or
mortality
 ASA (American Society ofAnesthesiologists) Grading
 Physiological and Operative Severity Score for the
enUmeration of Mortality and morbidity POSSUM score
 Lee’s Revised Cardiac Risk Index

32. Conclusion
Assessments made during the preanesthetic
evaluation may be used to:
• Educate the patient
• Organize resources for perioperative care
• Formulate plans for intra-operative care, postoperative
recovery, and postoperative pain management.

33. Conclusion
 These would help the patient and family prepare for
the best possible outcome.
 Failure to undertake this activity places the patient at
increased risk of perioperative morbidity or mortality.

34. References
 Smith and Aitkenhead’s Textbook of Anaesthesia Sixth
Edition By Alan R. Aitkenhead, Iain K. Moppett And
Jonathan P. Thompson
 Airway Assessment : Predictors Of Difficult Airway ,Dr.
Sunanda Gupta1 Dr. Rajesh Sharma Kr2 Dr. Dimpel Jain
 2016 Toronto Notes, Comprehensive medical reference and
review for the Medical Council of Canada Qualifying Exam
Part I and the United States Medical Licensing Exam Step 2
32nd Edition, Editors-in-Chief: Zamir Merali and Jason D.
Woodfine

35. Thank you