Routine preoperative investigations

Check local hospital policy.

• Urinalysis • All patients: for sugar,
blood and protein
• ECG • Age> 50 years
• History of heart disease,
hypertension or chronic
lung disease
• A normal previous trace
within 1 year is
acceptable unless there
is a recent cardiac history
• FBC • Males > 40 years
• All females
• All major surgery
• Whenever anemia is
suspected
• Blood urea, • Age >50 years
electrolytes and • All major surgery
creatinine Diuretic drugs
• Suspected renal
disease
• Blood glucose • Diabetic patients
• Glycosuria
• Age > 50 years

• Coagulation screen • History of bleeding

tendency (some units
measure before major
surgery)
• Black patients with
• Sickle cell test
unknown sickle status. If
positive then hemoglobin
electrophoresis should be
performed
• Pregnancy test • whenever there is any
chance of pregnancy

• Chest radiograph • Not routine

• Acute cardiac of chest
disease
• Chronic cardiac or chest
disease that has
worsened in the last year
• Risk of pulmonary TB
(recent arrival from the
developing world or
immunocompromis)
• Malignant diseases
Consent
• All competent patients have to give or with
hold consent for treatment or examination
• To obtain consent , the patient must be
given sufficient details and information
about the procedure to enable proper
decision to be taken
• In an emergency, consent is not
necessary for life-saving procedures
•Risk

In order to appreciate risk the patient

needs to be told of the likelihood of the
complication occurring and this should be
put into context by using an analogy from
everyday life
• Negligible risk frequency less than 1:1000 000, i.e. the
risk of dying from lightening strike.
• Minimum risk: frequency 1: 100 000-1000 000, i.e. the
risk of dying on the railways
• Very low risk: frequency 1: 10 000-1:100 000 i.e. the
annual risk of dying of traffic accident at home or at work
• Low risk: frequency 1-1000-10 000, i.e. the annual risk of
dying in a road traffic accident.
• Moderate risk: frequency 1: 100 to 1:1000 i.e. the risk of
death from natural causes for patients over 40 within the
next year
• High risk : frequency greater than 1: 100 the risk of
developing diarrhea after antibiotics
In addition to the frequency of the risk, the
seriousness must be considered
Competence

Adult patients who are able to make

decision on their own about their treatment
are considered competent. This means
that they must be capable of
understanding and remembering the
information given about the procedure,
and be able to weigh up the risks and
benefits to arrive at a balanced choice. For
competent patients, no other person can
consent or refuse treatment on their behalf
Restricted consent

• Some patients may consent to treatment

in general, but refuse consent for certain
aspects of the treatment, e.g. Jehovah's
Witness patients who refuse blood
transfusion

• The patient's wishes must be respected

Research
All clinical research requires Research
Ethics Committee approval
Teaching
Students must not take part in clinical procedures
without the patients consent

Documentation
The anesthetic plan discussed and agreed with the
patient should be documented including the
risks which have been explained
Physical status classification of the
American Society of
Anesthesiologists (ASA)
• Physical Status • Description
Classification

PS-1 a normal healthy patient

• PS-2 • A patient with mild
systemic disease that
results in no
functional limitation
Examples:
Hypertension.
Diabetes mellitus,
chronic bronchitis.
Morbid obesity,
extremes of age
• PS-3 • A patient with severe
systemic disease that
results in functional
limitation
• Examples: Poorly
controlled
hypertension.
Diabetes mellitus with
vascular complication,
angina pectoris, prior
myocardial infarction
• Pulmonary disease
that limits activity
• PS-4 • A patient with severe
systemic disease that
is a constant threat to
life
• Examples
congestive heart
failure, unstable
angina pectoris
advanced pulmonary,
renal or hepatic
dysfunction
• PS-5 • A moribund patient
who is not expected
to survive without the
operation
• Examples: Ruptured
abdominal aneurysm,
pulmonary embolus,
head injury with
increased intracranial
pressure
• PS-6 • A declared brain –
dead patient whose
organs are being
removed for donor
purposes
• Emergency Any patient in whom an
Operation (E) emergency operation
is required
Example: an otherwise
healthy 30-year –old
female who requires
dilation and curettage
for moderate but
persistent vaginal
bleeding (PS-1E)
 Fasting
• Pulmonary aspiration of gastric contents is
associated with significant morbidity and
mortality.

• Factors predisposing to regurgitation and

pulmonary aspiration include:
• Pregnancy
• Obesity
• Difficult airway
• Emergency surgery, trauma
• Full stomach
• Altered gastric motility (head injury)
• Anesthesia drugs, opioids
• Metabolic causes (poorly controlled DM,
renal failure)
• Pyloric obstruction
ASA Fasting guidelines
Ingested material Minimum fast
• Clear liquids 2h
• Breast milk 4h
• Infant formula milk 4-6 h
• Non human milk 6h
• Light meal 6h
• Heavy meal (contain 8h
fat &meat)
Approaches to the problem of Acid
Aspiration
1. Decrease gastric fluid volume
• Restrict intake
• Empty stomach:
-Physical (NG-tube)
-Pharmacological (Apomorpheine)
• Suppress gastric secretion(H2-blockers,
Atropine)
2. Decrease gastric fluid acidity
• Neutralise existing acid (30ml sodium citrate)
• Elevate pH, pharmacological (Ranitidine,
cimetidine)

3. Prevent regurgitation
• Increase tone of lower oesophageal sphincter
(Metoclopromide, alkalinisation of stomach)
• Avoid increase in intra-gastric pressure
(prevent fasciculation)
• Cricoid pressure
4. Prevent inhalation if regurgitation occurs
• Induction in lateral position
• Powerful sucker available

5. Avoid intubation Difficulties

• Careful patient assessment
• Skilled anesthesiologist

6. Avoid general anesthesia

• Regional or local anesthesia
Thank you