Pac anaesthesia - importance of history taking

1. Pre Anaesthesia
Evaluation
Presented by : Dr Sushma
Moderator : Dr Harshal
Consultant Anaesthetist , KIMS

2. PREOP EVALUATION
• A process of clinical assessment that precedes
the delivery of anesthesia for surgical and non
surgical procedures.
• Guides the anesthetic plan
An opportunity for the anesthesiologist to:
• Describe the proposed anesthetic plan
• Psychological support to the pt
• Obtain informed consent

3. Preop Evaluation
• Inadequate preoperative planning and
incomplete patient preparation are commonly
associated with anesthetic complications.

4. Purpose of effective pre op evaluation
• To identify those few patients whose
outcomes will be improved by
implementation of a specific medical
treatment eg: 60 y/o patient scheduled for
elective total hip arthroplasty who also has
unstable angina from left main coronary
artery disease would more likely survive if
coronary artery bypass grafting is performed
before the elective procedure

5. Purpose of effective pre op evaluation
• To identify patients whose condition is so
poor that the proposed surgery might only
hasten death without improving the quality
of life . eg, a patient with severe chronic lung
disease, end-stage kidney failure, liver failure,
and heart failure likely would not survive to
derive benefit from an 8-hour, complex,
multilevel spinal fusion with instrumentation.

6. Purpose of effective pre op evaluation
• To identify patients with specific
characteristics that likely will influence the
proposed anesthetic plan eg: the anesthetic
plan may need to be reassessed for a patient
whose trachea appears difficult to intubate,
one with a family history of malignant
hyperthermia, or one with an infection near
where a proposed regional anesthetic would
be administered.

7. • To provide the patient with an estimate of
anesthetic risk . However, the anesthesiologist
should not be expected to provide the risk-
versus-benefit discussion for the proposed
procedure(responsibility of the surgeon)

8. Elements of the Preoperative History
Patients presenting for elective surgery and
anesthesia typically require a focused
preoperative medical history emphasizing
• Cardiac
• Pulmonary function
• Kidney disease
• Endocrine and metabolic diseases
• Musculoskeletal
• Anatomic issues relevant to airway management
and regional anesthesia
• Responses and reactions to previous anesthetics.

10. History Taking
• Demographic details
• Present medical history (Presenting complaint/
History of presenting complaint)
• Past medical history
• Surgical history / Previous anesthetic history
• Drug history(allergies/present medications)
• Family history
• Social history

11. Demographic Details
Date & time of examination
Patient’s name
Age
Sex
Weight

12. Past Medical History

13. Goals
• To ensure that the patient is in the optimal
condition.
• Patients with unstable symptoms should be
postponed for optimization prior to elective
surgery.
• Anesthetic drugs and techniques have profound
effects on human physiology
• Hence, focused review of all major organ system
should be done prior to elective surgery.

14. Cardiovascular Issues
Preoperative cardiac assessment:
• Whether the patient’s condition need to be
improved prior to the sx
• Need for any further cardiac evaluation prior
to the surgery

15. CVS
Symptoms of the following problems
Active Cardiac Conditions
• Unstable coronary syndromes
• Unstable or severe angina
• Recent MI
• Decompensated HF
• Significant arrhythmias
• Severe valvular disease

16. Specific enquiries must be made
about
Coronary Artery Disease
Determine
• Type
• Severity
• Functional limitation

17. RISK FACTORS OF CAD
• Age over 45
• Obesity
• Angina
• Prior MI or CHF
• Dysrrhythmias

18. Angina
• Chest pain at rest/with mild exercise, Freq and
duration
• Incidence , precipitating factors, duration of
use of anti-anginal medications, e.g. Glyceryl
trinitrate (GTN) oral or sublingual )
• Stable angina – proceed wd sx
• Unstable angina- em sx only

19. Ischemic Heart Disease
There is a high incidence of both silent MI and
myocardial ischaemia in diabetics.
High risk :
• MI wd in past 6m
• CHF
Extremely high risk
• Signs: orthopnea sweating palpitations night
coughing

20. H/o previous myocardial infarction and subsequent
symptoms indicating heart failure /MI are at a
greater risk of perioperative reinfarction .
• Elective surgery postponed until at least 6
months after the event

21. Valvular Heart Disease
• Prosthetic valves - on anticoagulants
• Acs need to be stopped or changed (bridging
therapy)prior to surgery
• Antibiotic prophylaxis
Heart Failure
• Symptoms : fatigue ,palpitations ,sweating
,dyspnea ,chest pain, syncope
• worsened by the depressant effects of
anaesthetics impairing the perfusion of vital
organs

23. HYPERTENSION

24. HYPERTENSION
• How long
• Tx
• Compliance with tx
• How well it is controlled

25. Severe HTN
• Systolic >195
• Diastolic>100
• Delay non urgent sx
• Obtain approp consultation and Rx
Mild HTN
• Systolic <165
• diastolic<100
• Evaluate other risks
• Proceed with caution
• Obtain approp followup

26. HYPERTENSION
• Untreated and poorly controlled HTN may
lead to exaggerated cardiovascular responses
during anesthesia.
• Both HTN and hypotension can be
precipitated, which increase the incidence of
both mycardial and cereberal ischaemia.

27. HTN
• Controversy regarding delay or cancel a sx in a
patient with untreated or inadequately treated
hypertension.
• In patients with blood pressure above 180/100
mm hg , in the absence of end organ changes,
such as renal insufficency , LVH with strain the
benefits of optimizing BP must be weighed
against the risk of delaying surgery.

28. REVISED CARDIAC RISK INDEX (cardiac pts undergoing
elective major non cardiac procedures)

29. Surgical Risk Stratification (for cardiac pt
undergoing non cardiac sx)

30. Clinical Predictors Of Increased Perioperative
CVS Risk(MI,CHF,death)
MAJOR
• Unstable coronary syndromes
• Recent MI with evidence ischaemic risk by clinical
symptoms or noninvasive study
• Unstable or severe angina
• Decompensated CHF
• Significant arrythmias - High grade AV block,
Symptomatic ventricular aarythmias in the presence of
underlying heart disease, Supraventricular arrythmias
with uncontrolled ventricular rate.
• Severe valvular disease.

31. Clinical Predictors Of Increased
Perioperative CVS Risk
INTERMEDIATE
• Mild angina
• Prior MI by history or pathological Q waves
• Compensated or prior CHF
• Diabetes mellitus

32. Clinical Predictors Of Increased
Perioperative Cvs Risk
MINOR
• Advanced age
• Abnormal ECG (LVH,LBBB, ST-T abnormalities)
• Arrhythmias (e.g- AF)
• Low functional capacity (e.g- inability to climb
one flight of stairs )
• History of stroke
• Uncontrolled systemic HTN

33. Functional Capacity – (MET )Metabolic
equivalents
• A unit of functional activity
• Expressed as a multiple of current metabolic
rate to the resting metabolic rate
• It is the rate of energy consumption where
1met is the basic metabolic consumption
• 1met =3.5mloxygen/kg/min(resting metab
consumption)
• Lowest met =0.9(sleeping)

34. METS
• To withstand the stress of sx pts should
achieve 4mets of functional capacity
• Perioperative cardiac and long-term risks are
elevated in patients unable to obtain 4-MET
demand
• Able to climb 2flights of stairs without getting
tired indicates good reserve - FC>4mets

35. METS

36. METS

37. CENTRAL NERVOUS SYSTEM
Problems
• Ischemia/vasospasm
• Embolism/thrombosis
• Tumor
• Aneurysm/haemorrhage
• Seizures - well controlled or not
• stroke
• Correlate h/o with physical findings

38. CNS
Signs and symptoms
• Nausea /vomiting
• Vertigo
• Headache /vision disturbances
• Htn/brady
• Focal sensory/motor defecits
• Slurred speech
• Confusion/disorientation
• Coma

39. Peripheral Neuropathy
Signs and symptoms
• Weakness or loss of function
• Tingling/numbness
• Cold/pale extremities
• Diminished reflexes

40. Peripheral Neuropathy
Causes:
• Autonomic dysfunction
• Dm
• Drug induced neuropathy
• Nerve compression
Get neuro consultation for new symptoms
Evaluation prior to regional anaesthesia

41. HEPATIC SYSTEM
• H/o jaundice/hepatitis
Viral hepatitis
• Easily transmitted
• Nonsp symptoms like fatigue, malaise, vague
abd pain
• Symptoms of hepatitis: spider navi , ascites,
generalised tremor ,confusion /disorientation

42. HEPATIC SYSTEM
Coexsisting diseases
• Obesity
• Fatty liver
• Alcohol abuse
• Multiple blood transfusions
• Recreational drug use
• Coagulation disorders

43. RENAL SYSTEM
• Probs wd urination
• Chronic cystitis
• Prostatitis
• Renal calculi
• ARF/CRF
• Electrolyte abnormalities
• Hypervololemia HTN Hyperkalemia

44. RENAL
ARF/CRF
• Get accurate h/o dialysis schedule , last
dialysis, RFT& electrolytes after dialysis
Chronic renal failure
• Anaemia
• Electrolyte abnormalities
• Altered drug excretion restricts the choice of
anaesthetic agents

45. RESPIRATORY SYSTEM
• Detailed History of recent URTI, sorethroat ,
productive cough, dyspnea(exertion/rest),
allergies(hay fever),sleep apnea
• Acute disease:
URTI/Asthma/Bronchitis/Pneumonia
• Chronic disease: COPD/TB
• Asthma: duration ,last episode, hospitalisation ,tx
(bronchodilators)
• COPD-productive cough , smoking packs perday

46. RESPIRATORY SYSTEM
Pulmonary complications occurs more frequently than
cardiac complications (5-10% incidence )
• Perioperative complications includes:
1. Aspiration
2. Atelectasis
3. Pnuemonia
4. Bronchitis
5. Bronchospasm
6. Hypoxemia
7. AE COPD
8. Respiratiory failure requiring mechanical ventilation

47. Cases where there is markedly increased
risk of pulmonary complications
• ASA class 3 and class 4 patients ( compared to class 1)
• Cigarette smoking
• Longer surgeries(>4 h)
• Certain types of surgeries:
 Abdominal
 Thoracic
 Aortic aneurysm
 Head and neck
 Emergency surgery
• General anesthesia (compared with cases in which GA was
not used)

48. Efforts required for prevention of
pulmonary complications
• Cessation of smoking prior to surgery
• Lung expansion techniques (eg, incentive
spirometry) after surgery in patients at risk.
• Patients with asthma, have a greater risk for
bronchospasm during airway manipulation.
• Appropriate use of analgesia and monitoring
are key strategies for avoiding postoperative
respiratory depression in patients with
obstructive sleep apnea.

49. GASTRO INSTESTINAL SYSTEM
• Nutritional status
• Obese/anorexic
• Wt gain/loss
• Gastric reflux
• Evaluate aspiration risk

50. GASTRO INTESTINAL SYSTEM
The risk of aspiration is increased in certain groups
of patients
• Morbidly Obese
• Pregnant women in the second and third
trimesters
• Hiatus hernia
• Full stomach (em sx / trauma)
• Serious gastroesophageal reflux disease (GERD).

51. Severe GERD:
Treat patients with consistent symptoms
(multiple times per week) with
• Medications (eg, nonparticulate antacids such
as sodium citrate)
• Techniques (eg, tracheal intubation)

52. 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 content
• Proton pump inhibitors: supress gastric acid
secretion by binding proton pump of the parietal
cell
• Prokinetic agents : Metoclopramide (Dopamine
antagonist)

53. COAGULATION ISSUES
• How to manage patients who are taking
warfarin on a long-term basis(anticoagulants)
• How to manage patients who are taking
clopidogrel and related agents(antiplatelets)
• How to safely provide regional anesthesia to
patients who either are receiving long-term
anticoagulation therapy or who will receive
anticoagulation perioperatively.

54. ANTICOAGULANTS
Patients at high risk for thrombosis:
Mechanical heart valve implants
 Atrial fibrillation
Prior thromboembolic stroke
Bridging Therapy

55. ANTICOAGULANTS
• Patients at lower risk for thrombosis may have
warfarin discontinued and then reinitiated
after successful surgery.
• Decisions regarding bridging therapy often
require consultation with the physician who
initiated the warfarin therapy

56. ANTIPLATELETS
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 in patients who have
drug eluting coronary stents until they have
completed 12 months of dual anti platelet
therapy.

57. ANTIPLATELETS
Thienopyridines (clopidogrel and ticlopidine)
• Cataract Surgery –no need to stop
• If reversal of platelet inhibition is necessary, then
clopidogrel must be stopped 7 days before &
Ticlopidine – 14 days before surgery
• Do not discontinue them in Pts who have drug
eluting stents before 1 year

58. Endocrine And Metabolic Issues
• Blood glucose measurement on the morning
of elective surgery
• Adequacy of longterm blood glucose control -
Hba1c .
• Abnormally elevated Hba1c - referral to a
diabetology service for education ,diet
modification and medications to improve
metabolic control may be beneficial.

59. Endocrine And Metabolic Issues
• Elective surgery should be delayed in patients
presenting with marked hyperglycemia
• Rearranging the order of scheduled cases to
allow insulin infusion to bring the blood
glucose concentration closer to the normal
range before surgery begins .

60. Endocrine And Metabolic Issues
Type1 IDDM
End organ disease is common
• Retinopathy
• Nephropathy
• Autonomic dysfunction
T2- NIDDM

61. Endocrine And Metabolic Issues
Diabetes patients have an increased incidence of
• Ischaemic heart disease
• Renal dysfunction
• Autonomic and peripheral neuropathy
• Intra- and postoperative complications

62. Dm - goals of Mx
• Maintain blood glucose 100-250mg/dl
• Provide adequate fluid volume

63. Endocrine And Metabolic Issues
• Hyperthyroid: excessive t3t4 secretion; low
TSH
• Signs and symps: hypermetab exophthalmous
tx propylthiouracil betablockers
• Hypothyroid; low t3t4 ; high TSH
• Signs and symptoms: low metabolism large
tongue
• Tx eltroxine

64. Endocrine And Metabolic Issues
Hyperparathyroidism:
• Hypercalcemia
• Increased bone resorption
• Reduced renal excretion
• Diagnosis; high sr calcium high pth

65. Endocrine And Metabolic Issues
Pheochromocytoma:
• Tumor of chromaffin tissue
• Inc production & release of epinephrine &
norepi
• S&S: intermittent HTN, headache, sweating,
tachy
• Diagnosis: inc sr epi , nor epi / Inc urine
vinylmandelic acid & metanephrine

66. Endocrine And Metabolic Issues
Carcinoid tumors
• Slow growing gi tumors
• Release vasoactive amines & polypeptides
5hydroxytryptamine
• Diarrhoea
• Abd cramps
• Respi distress/bronchospasm
• HTN
Histamine abd bradykinin release
• Paroxysnal hypotension
• Cutaneous flushing
• Bronchospasm

67. Endocrine And Metabolic Issues
Adrenocortical dysfunction – cushing syndrome
• Tx- correct fluid vol status /electrolyte
abnorm/ steroids

68. HEMATOLOGIC SYSTEM
Anemia
• Hb for o2 delivery
• Causes acute/chronic anemia
• Any benefit from delay of sx
• Acute bl loss-poorly tolerated

69. MUSCULOSKLETAL SYSTEM
Rheumatoid arthritis
• Duration, tx h/o - aspirin /nsaids/ steroids
• Chronic anemia
• Severely limited movement of their joints makes
positioning for surgery and airway maintenance
difficult.
• Tendency for dislocation of atalnto-occiptal joint
• Osteoarthritis
• Muscular dystrophies

70. MUSCULOSKLETAL SYSTEM
Neuromuscular disorders
• Care with muscle relaxants
• Coexisting heart disease
• Restrictive pulmonary disease

71. OBESITY
Determine Ideal bwt and BODY MASS INDEX
Ideal bwt (kgs):
• Broca Index = ht(cms)-105 women
ht(CMS) -100 men
BMI=Wt(kg)/Ht(m2)

72. Obesity Classification

73. OBESITY

74. MORBID OBESITY

75. Obstructive sleep apnea
• OSA is episodic upper airway narrowing during sleep.
• During sleep, the activity of the upper airway dilator
muscles decreases in a sleep-stage-dependent manner
• This leads to narrowing of the upper airway, loud
snoring, and reduction in airflow
• Can either be partial (a hypopnoea), or complete (an
apnoea).
• Apnoea Hypopnoea Index (AHI)
The total number of apnoeas and hypopnoeas per hour
of sleep
Used to describe the severity of OSA

76. Obstructive sleep apnea
• OSA severity -AHI
No OSA- AHI < 5/h,
Mild OSA - AHI 5–15/h,
Moderate OSA- AHI 15–30/h
Severe OSA- AHI > 30/h
• Gold standard - Polysomnography or multi-
channel respiratory polygraphy (“sleep study”)
• Questionnaires to assess OSA risk - to screen for
OSA and to assess the prevalence of OSA

77. STOP BANG questionarre -Screening tool
for OSA

78. FAMILY HISTORY
• Inherited conditions in the family
• History of prolonged apnoea , unexplained
death

79. Surgical History & Previous
Anaesthesia Exposure
Difficulties with previous anaesthetics
• Procedure difficulties
• Nausea
• Vomiting
• Dreams
• Awareness
• Postoperative jaundice

80. Surgical History & Previous
Anaesthesia Exposure
History of difficulty with venous access
• Thrombosis of vein
• Look for tattooing

81. DRUG HISTORY AND ALLERGIES
• Identify all medications
• Prescribed/self-administered
• Allergies to- drugs /topical preparations
(e.g.iodine)/adhesive dressings/ food

82. SOCIAL HISTORY
Alcohol : duration / frequency
• Alcohol induction of liver enzymes
• Tolerance
Smoking: number of cigarettes /amount of tobacco
• Nicotine stimulates the sympathetic nervous
system causing tachycardia ,hypertension
,coronary artery narrowing, hyperactive airways
• Look for withdrawal symptoms

83. Preparation For Anesthesia
• Continuing current medications/ treatment of
coexisting diseases
• Responsibility of the anesthesiologist to
instruct patients regarding which medications
to continue and which to hold preoperatively

84. Instruct Patients to take the medications
with small sips of water, even if fasting!
Medications to be Continued on the day of Surgery
• Antihypertensives except ACEI is and ARBs
• Cardiac medications e.g beta- blockers, digoxin ,antianginal
• Antidepressants, anxiolytics and other psychiatric medications
• Antiparkinson drugs
• Thyroid medications
• Birth control pills
• Eye drops
• Heartburn or reflux medications
• Narcotics
• Anticonvulsants
• Asthma medications
• Steroids
• Statins

85. Medications to be discontinued
• Topical medications e.g creams and ointment
• Oral hypoglycemic agents -on the day of sx
• Insulin -on the day of sx
• Diuretics (except Thiazides for bp or severe HF) -
on the day of sx
• Sildenafil(similar drugs )-24 hrs before Sx.
• NSAIDS –48 hrs before Sx.
• Warfarin ( Coumadin) 4 days before Sx
• Anticoagulants/antiplatelets

86. ASRA GUIDELINES

92. Summary
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
intraoperatively becomes easier, and they are
more likely to have a positive outcome as well
as a satisfied patient.