The document discusses the importance of preoperative evaluation in anesthesia. It notes that anesthesiologists now perform many roles beyond just anesthesia in the operating room, including focused clinical exams, medical optimization, reducing patient anxiety, and informed consent. A thorough preoperative evaluation can reduce surgical risks, delays and cancellations. Key aspects of the evaluation include assessing medical history and physical exam findings, laboratory tests, EKG, and risk classification using the ASA system. The goals are to identify health risks, heart conditions, optimize medical issues, and modify perioperative risk.

1. Preoperative
Evaluation 1
Mansoor Masjedi MD , FCCM
Grand round of anesthesia dept.,
SUMS , 21st
. Nov. 2013

2. Unique, remarkable, and revolutionary
event has occurred in the field of
anesthesia
Many anesthesiologists have essentially replaced
multiple medical specialties
in patients being prepared for surgery

3. besides
Anesthesia care is no longer limited to
the operating room
Many departments of anesthesiology
changed to
“anesthesia and perioperative care”

4. Anesthesiologists preoperatively perform:
1.Focused clinical examinations
2.Plan for medical intervention and optimization
3.↓patient's & family's anxiety and fears
4.Discuss periop. care & postop pain control
5.Laboratory tests and diagnostic studies
6.Discuss anesthesia risks
7.Obtain informed consent

5. Anesthesia preop. evaluation can :
 ↓surgical morbidity
 ↓delays & cancellations on the day of
op.
 ↑perioperative efficiency

6. Pre-Anesthesia
Assessment
PATIENT PERSPECTIVE

7. Preoperative Risk Assessment
The concept of risk associated with
anesthesia is unique in that rarely does the
anesthetic itself offer benefit but merely
allows others to do things that potentially
offer benefit

8. Preoperative Risk Assessment
 11.6% of reports identified inadequate or
incorrect preoperative assessment
 communication failure was cited as the
most significant factor (preoperative
evaluations moments before op.)

9. 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
Preoperative Risk Assessment
ASA Physical Status Classification System
For emergent operations, you have to add the letter ‘E’ after the classification.

10. ASA risk classification system;
limitations
 Neither the type of anesthesia
 Nor the location of Op.
 Most importantly, no attempt to quantify
the risk

11. Detecting Disease in Preoperative Evaluation

12.  56% of correct diagnoses were made with the
Hx. alone, which increased to 73% with the
addition of P/E
 cardiovascular disease : C-xray & ECGs
helped with only 3% of diagnoses, and special
tests (e.g., exercise ECG) assisted with 6%

13. 1 Eating, working at a computer, dressing
2 Walking down stairs or in your house, cooking
3 Walking 1-2 blocks
4 Raking leaves, gardening
5 Climbing 1 flight of stairs, dancing, bicycling
6 Playing golf, carrying clubs
7 Playing singles tennis
8 Rapidly climbing stairs, jogging slowly
9 Jumping rope slowly, moderate cycling
10 Swimming quickly, running or jogging briskly
11 Skiing cross country, playing full-court basketball
12 Running rapidly for moderate to long distances

14.  At a minimum, the preanesthetic examination
should include vital signs (BP, HR, RR,T, Spo2),
height, and weight
 BMI is more accurate than weight in
establishing obesity
 ↑BMI is predictive of airway difficulties &
development of chronic diseases such as heart
disease, cancer, and diabetes

15.  Length of the upper incisors
 Condition of the teeth
 Ability to protrude or advance the lower incisors in front of the
upper incisors ( ULBT )
 Interincisor or intergum (if edentulous) distance
 Tongue size
 Visibility of the uvula
 Presence of heavy facial hair
 Compliance of the mandibular space
 Thyromental distance with the head in maximum extension
 Length of the neck
 Thickness or circumference of the neck
 Range of motion of the head and neck

17.  Cardiovascular complications are the most
common serious perioperative adverse event
 Cardiac morbidity will occur in 1% to 5% of
unselected patients undergoing noncardiac
surgery

18.  ≥ 2 BP greater than 140/90 mm Hg, affects 1
billion individuals worldwide
 End-organ damage and morbidity and
mortality correlate with the duration and
severity of HTN
 IHD is the most common type of organ damage
associated with hypertension
 Each 20 mm Hg ↑SBP or 10–mm Hg ↑DBP above
115/75 , doubles the lifetime risk for
cardiovascular dis. (in 40 to 70 y/o)

19.  Hx. & P/E : determine cardiac, neurologic, or
renal dis. (important)
 If severe end-organ damage normalize BP as
much as possible before surgery

20.  Postpone elective op if severe hypertension
(DBP >115 mm Hg, SBP >200 mm Hg) until BP
≤180/110
 lowering of risk requires 6 to 8 wks of Rx
(regression of vascular and endothelial
changes)
 Too rapid or extreme lowering → ↑cerebral
and coronary ischemia
 Benefits of delaying op for Rx must be
weighed against the risks

21.  Cardioselective β-blocker therapy is the best
treatment preoperatively because of a
favorable profile in lowering cardiovascular
risk
 Perioperative Ischemia Evaluation (POISE) trial
has recently questioned the safety of starting
these agents acutely
 The optimal time to start β-blocker therapy to
achieve its benefit while minimizing risk is
unknown

22.  Periop stroke, role of β blockers in general and metoprolol in
particular
 Routine use of preop metoprolol, but not atenolol, is associated
with stroke after noncardiac sx., even after adjusting for
comorbidities
 Intraoperative metoprolol but not esmolol or labetalol, is ass.
with increased risk of periop stroke
Drugs other than metoprolol should be considered
during the perioperative period if blockade isβ
required

24.  The goals of preop evaluation are to:
1) Identify the risk for heart disease based on risk
factors
2) Identify the presence and severity of heart disease
from symptoms, physical findings, or diagnostic
tests
3) Determine the need for preoperative interventions
4) Modify the risk for perioperative adverse events

25. 1. High-risk surgery (intraperitoneal, intrathoracic, or
suprainguinal vascular procedures) *
2. IHD (by any diagnostic criteria)
3. Hx of CHF
4. Hx of cerebrovascular dis.
5. IDDM [†]
6. Cr. >2.0 mg/dL
 * This risk factor is not considered a clinical predictor in the ACC/AHA 2007 guidelines for
perioperative cardiac evaluation for noncardiac surgery
 † This risk factor has been changed to simply diabetes mellitus in the ACC/AHA 2007
guidelines for perioperative cardiac evaluation for noncardiac surgery

27. Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply.
Fleisher, L. A. et al. J Am Coll Cardiol 2007;50:e159-e242
Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical
conditions, known cardiovascular disease, or cardiac risk factors for patients 50 years of
age or greater

28.  Patients with risk factors for CAD or symptoms
suggestive of ischemia, including atypical
ones such as dyspnea, need an ECG
 An ECG should not be ordered simply because
of advanced age
 Establishing a baseline for comparison is the
most important reason to obtain an ECG
preoperatively

29.  Class IClass I
 At least one clinical risk factor * undergoing vascular surgical
procedures
 Known CHF, peripheral arterial disease, or cerebrovascular dis.
undergoing intermediate-risk surgical procedures
 Class IIaClass IIa
 No clinical risk factor undergoing vascular surgical procedures
 Class IIbClass IIb
 At least one clinical risk factor undergoing intermediate-risk
operative procedures
 Class IIIClass III
 Not indicated for asymptomatic persons undergoing low-risk surgical
procedures
Class I recommendations: the procedure should be performed; class IIa: it is reasonable to
perform the preocedure; class IIb: the procedure may be considered; class III: the
procedure should not be performed because it is not helpful

30.  Noncardiac surgery soon after
revascularization (CABG or PCI with or without
stents) is associated with high rates of
perioperative cardiac morbidity and mortality
 Patients who need noncardiac surgery within
the next year are not good candidates for
implantation of drug-eluting stents, and if
revascularization is absolutely necessary, these
patients need to be considered for either CABG
or PCI without stenting or with a bare metal
stent

31.  Cardiac catheterization, which some consider
the gold standard for evaluation of coronary
lesions, does not absolutely risk-stratify
patients
 Perioperative cardiac risk increases with
increasing amounts of at-risk myocardium
 If a patient has undergone a specific test in
the past, it is most useful to obtain the same
test for comparison

34.  2% of the population in USA
 Significant risk factor for postop adverse
events
 One in 100 individuals between 50 and 59
y/o has a 5% to 7% risk of perioperative
cardiac complications, but those with
decompensated failure have a 20% to 30%
incidence

35.  IHD is the most common cause of systolic
dysfunction in the United States (50% to 75%
of cases
 In patients undergoing noncardiac surgery,
preoperative BNP levels predict cardiac
complications and death

36.  Class I: no limitation of physical activity; ordinary
activity does not cause fatigue, palpitations, or syncope
 Class II: slight limitation of physical activity; ordinary
activity results in fatigue, palpitations, or syncope
 Class III: marked limitation of physical activity; less
than ordinary activity results in fatigue, palpitations, or
syncope; comfortable at rest
 Class IV: inability to perform any physical activity
without discomfort; symptoms at rest

37.  Continuing or discontinuing anti failure drugs
depends on:
Volume and hemodynamic status of the pt
Degree of cardiac dysfunction
Anticipated surgery and volume challenges

39.  Class IClass I—echocardiography is usefuluseful in asymptomatic patients with the
following cardiac murmurs:
 Diastolic murmurs
 Continuous murmurs
 Late systolic murmurs
 Murmurs associated with ejection clicks
 Murmurs that radiate to the neck or back
 Grade 3 or louder systolic murmurs

 Class I1aClass I1a —in favor of the usefulnessin favor of the usefulness of echocardiography in asymptomatic
patients with the following cardiac murmurs:
 Murmurs +abnl heart P/E
 Murmurs +abnl EKG or C-xray

 Class IIIClass III — echocardiography is not usefulnot useful in
 asymptomatic pts + Grade 2 or softer midsystolic murmurs considered
innocent or functional by an experienced observer

40. The most important preop. issues are:
Underlying condition requiring replacement
Type of prosthesis
Need for anticoagulation
Periop. management

41.  Risk of thrombosis:
 Multipe prosthetic valaves >mitral v. > aortic v.
 Caged-ball valves >single tilting-disk
valves>bileaflet tilting-disk prostheses
 Bioprosthetic valves generally do not require
long-term anticoagulation

42.  Decision
 To stop anticoagulants
 Duration off anticoagulants
 To “bridge” with a shorter-acting drug
 Type of bridging agent (heparin or LMWH)
need to be made in conjunction with the treating
cardiologist and surgeon

44.  Classification
 Intermittent (paroxysmal),
 Persistent (able to be cardioverted)
 Permanent (unable to be converted)
 Rate control is more important than rhythm
control
 Patients with rapid ventricular rates (>100
beats/min) require control before elective
surgery

45.  Ventricular vs atrial ectopics
 wide QRS (>0.12 msec)
 lack of a P wave
 The traditional grading system of Lown,
organized by morphology (unifocal or
multifocal), frequency (less than or greater
than 30 beats/min), and other
characteristics (couplets, R on T
phenomenon), is limited in its ability to
stratify risk

46.  BenignBenign: isolated VPBs without heart disease
 No need for further evaluation
 No risk of sudden cardiac arrest
 Potentially lethalPotentially lethal: >30 VPBs/hr or nonsustained VT with
underlying heart dis
 Cardio consult with possible echocardiography, stress testing,
catheterization, or electrophysiologic testing
 Moderately high risk of sudden cardiac arrest; may benefit from an ICD
 LethalLethal: sustained VT, VF,syncope, or hemodynamic compromise
ass. with VPBs with underlying heart dis. & often depressed
cardiac function
 Requires cardiology evaluation with possible stress testing,
echocardiography, catheterization, or electrophysiologic testing
 High risk of sudden cardiac arrest; likely to benefit from an ICD


47. Thank you