The document outlines the critical components of preoperative assessment and preparation for anesthesia, emphasizing the importance of history taking, physical examinations, and necessary investigations to reduce surgical risks and improve patient outcomes. It details the structured approach to assess patients, including evaluating medical histories, surgical urgencies, and conducting relevant tests such as ECGs and blood counts. The goal of the preoperative assessment is to ensure patients are fully prepared for surgery, minimize complications, and enhance overall surgical management.

1. Preoperative assessment and
preparation for anaesthesia

2. Session outline
Preoperative assessment:
1. History taking
2. Physical examination
3. Surgical urgency
4. Investigations

3. Introduction: what is POA?

4. Introduction
What are the aims of POA?
 Reduce morbidity and mortality associated with surgery
 Assess pre-existing medical conditions
 Plan preoperative and postoperative management of these conditions
 Prevent unnecessary cancellations
 Ensure the patient is fully prepared for surgery
 Reduce length of hospital stay
 Inform the patient of the proposed procedure and gain consent

5. Introduction
 Why is POA important?
1. Induction is dangerous without correct preparation
2. Anaesthetic has profound effect on CVS and RS
3. Pre-existing medical conditions can have a dramatic influence
4. To enable you to adequately prepare for an anaesthetic type
5. To minimizes the risk to the patient
 Structured approach: Take a few moments to outline on a piece of paper a
plan for a preoperative assessment.

6. Preoperative assessment
1: History taking
 History of present compliant?
Determine surgical urgency
Influence of anaesthetic technique
Determine the acceptable starvation period
Surgical condition which have systemic effect. E.g. bowl ca

7. Anesthesia fitness chart

8. Preoperative assessment
1: History taking
Medical History – CV disease
 For cardiovascular disease, ask:
 Exercise tolerance
 Palpitations
 Collapse/syncope
 Ankle swelling
 History of MI/Hypertension/raised cholesterol/diabetes
 Known valvular or congenital heart disease

9. Preoperative assessment
1: History taking
 Medical History – RS disease
 For respiratory disease, ask:
 Exercise tolerance
 Cough/sputum/haemoptysis
 Smoking history
 Wheeze
 Exposure to industrial dusts
 Weight loss
 Night sweats
 Fever

10. Preoperative assessment
1: History taking
Medical history: exercise tolerance

11. Preoperative assessment
1: History taking
 Medical history: other conditions
 Malnourished
 Dehydration
 Elderly (>75 years)
 Diabetes mellitus
 Endocrine dysfunction
 Chronic renal failure
 Nephrotic syndrome
 Obstructive jaundice

12. Preoperative assessment
1: History taking
Medical history: Anaesthetic history
 Note details of previous anaesthetics and any problems
encountered
 Examine previous anaesthetic charts if available
 Note last exposure to halothane anaesthesia
Medical history: family history
 Malignant hyperthermia
 Suxamethonium apnoea
 Porphyria
 Haemoglobinopathies

13. Preoperative assessment
1: History taking
Medical history:
Drug history
Allergies and addiction
Pregnancy
Reflex

14. Preparation
 What should you prepare prior to anaesthetising a
patient for surgery?
1.Patients
2.Drugs and blood products
3.Equipment check
4.Communicate with ward
5.Communicate with theatre team

15. Preoperative assessment
2: physical examination
 Look at your patient as a whole to decide how sick
he/she is
 Assess the degree of hydration
 Check peripheral perfusion (is he cold to touch?).
 Check for cyanosis (central and peripheral).
 Check for jaundice

16. Preoperative assessment
2: physical examination
Cardiovascular System and respiratory Examination
Look
Listen(Auscultate)
Feel
 Look Other systems

17. Preoperative assessment
2: physical examination
Airway assessment
 Airway assessment aims to predict:
Difficult mask ventilation (with or without adjuncts/aids)
Difficult placement of LMA Difficult intubation
Difficult surgical access to trachea (rarely required)

18. Preoperative assessment
2: physical examination
Poor management of the difficult airway can result in:
Dental trauma
Airway trauma
Pulmonary aspiration
Hypoxia
Death

19. Preoperative assessment
2: physical examination
 Successful intubation requires:
Good mouth opening
Extension of the upper cervical spine
The ability to move soft tissue within the mandible out of the way

20. Preoperative assessment
2: physical examination
Quick airway assessment
 Mallampati test
 Mouth opening (interinciser gap)
 Jaw slide
 Neck movement

21. Preoperative assessment
2: physical examination

22. Preoperative assessment
2: physical examination
Mouth opening
Neck movement

23. Preoperative assessment
2: physical examination
Jaw slide
Thyro and sterno - mental distance

24. Difficult ventilation
 Which features are associated with difficult mask ventilation?
Overweight/Pregnant
Bearded or Burns/Trauma to face
Edentulous (lack of teeth)
Snoring/Obstructive Sleep Apnoea/space occupying lesion of
oropharynx or larynx
Elderly

25. Difficult intubation
 Which features are associated with difficult
intubation?
Protruding/awkward teeth
Space occupying lesion of oropharynx and larynx
Facial trauma or burns
Obesity
Previous tracheostomy/tracheal stenosis
Pregnancy

26. Preoperative assessment
3: surgical urgency
 Why for anaesthetist?
To communicate with surgeon
To minimize the overall risk
Aware the risks associated with the surgical urgency
Risk – benefit analysis
Consensus b/n the team and family

27. Preoperative assessment
3: surgical urgency
There are four categories:
Immediate life, limb or organ saving
Urgent
Expedited
Elective

28. Preoperative assessment
3: surgical urgency
Surgical grades Examples
 Grade 1 (minor)
 Excision skin lesion; drainage breast abscess
 Grade 2 (intermediate)
 Inguinal hernia; varicose vein(s); tonsillectomy; arthroscopy
 Grade 3 (major)
 Hysterectomy; TURP; lumbar discectomy; thyroidectomy
 Grade 4 (major+)
 Joint replacement; thoracic operations; colonic resection;
radical neck dissection

29. The ASA classification of general preoperative health
 Extended version
ASA 1: Healthy patient.
ASA 2: Healthy patient with
remarks.
ASA 3: Patient with moderate
clinical illness.
ASA 4: Severely ill patient.
ASA 5: Patient with an
immediately life-threatening
condition.
 Add E for emergency
Original version
 ASA I: A normal healthypatient
 ASA II: A patient with mild systemic disease
 ASA III: A patient with severe systemic disease
 ASA IV: A patient with severe systemic disease
that is a constant threat to life
 ASA V: A moribund patient who is not expected
to survive without the operation
 ASA VI: A declared brain-dead patient whose
organs are being removed for donor
purposes

30. Preoperative Assessment
4: Investigations
The decision to order tests will depend on:
 Age of the patient
 General health/co-morbidities of the patient
 Medications
 Presenting condition
 Urgency of surgery
 Nature of surgery planned
 Facilities available for testing

31. Age
 Healthy patients over 60 years old may need the
following if major surgery is planned:
 Electrocardiogram (ECG)
 Full blood count (FBC)
 Renal function tests (U&E)
 The type of surgery planned is a major determinant of
preoperative investigations.

32. Full blood count (FBC)
 Full blood count (FBC)
 Measure when:
 The history or examination indicates anaemia
 The proposed operation is expected to cause substantial
blood loss
 Measure in patients with:
 Jaundice
 Malignancy
 Infection
 HIV
 Significant blood loss
 Also measure in patients with cardiac/renal/respiratory
disease.

33. Blood test (Group save and cross much)
 Group and save
 According to hospital guidelines for elective surgery
 Significant or continuing blood loss but patient not shocked
 Cross match
 When blood is required Immediately if blood loss >30% circulating
blood volume (1.5 L in adult)
 If blood loss >50% circulating blood volume (2.5 L in adult); use O
negative blood until crossmatched blood becomes available

34. Blood test (coagulation screen)
 Measure when the patient :
 Has hepatic disease
 Is on warfarin or anticoagulants
 History of inappropriate excessive bleeding
 If there is a family history of bleeding disorders
 Severe sepsis
 Major haemorrhage

35. Blood glucose
Measure if the patient has:
Diabetes
Glycosuria
Steroid treatment
Altered conscious level

36. Radiograph
Chest
 Chest X rays (CXR) are not routinely ordered
 Usually limited to patients listed for major surgery with
 Substantial cardiac or respiratory disease,
 Heavy smoking or exposure to TB
 They may be requested as part of the surgical work up of the
patient.
 Acute respiratory symptoms:
 May require as part of their management
 These should be treated before elective surgery

37. Radiograph
Spine
Cervical spine x-rays (AP, lateral) are indicated in
• History of arthritis
• Susceptibility in clinical examination
• Trauma / RTA
• Diabetes

38. Electrocardiogram
 Consider when patient scheduled for major surgery has:
Cardiovascular risk factors or history of cardiovascular
disease for example: hypertension, smoking, high
cholesterol, significant family history, and obesity
Signs of heart failure
You suspect an arrhythmia from clinical examination
Atypical abdominal pain or cardiac sounding chest pain

39. Echocardiography
 Do not routinely offer resting echocardiography before
surgery.
 Consider resting echocardiography if the patient has:
 A heart murmur and any cardiac symptom (including breathlessness,
pre-syncope, syncope or chest pain) or
 Signs or symptoms of heart failure.
 Before ordering the resting echocardiogram, carry out a
resting electrocardiogram (ECG) and discuss the findings
with surgeon

40. Pulmonary function test
(Spirometry or PEFR)
 To assess the reversibility of obstructive airways diseases
 Useful to quantify severity of ventilatory dysfunction
 To differentiate restrictive from obstructive defects.
 May be indicated:
 Those with equivocal clinical and radiological findings or unclear
diagnosis.
 Patients in whom functional ability cannot be assessed
 Part of the assessment of patients for lung parenchymal resection

41. Renal function test
 Measure:
 For all major surgery
 Measure in patients on:
 On diuretics or cardiovascular drugs
 Measure in patients with:
 Infection
 Diabetes
 Dehydration
 Hypertension
 Poor urine output

42. Liver function tests
 Measure in patients with:
Cardiac/hepatic disease
Biliary disease
Infection
Alcohol abuse
Jaundice