Role of

anesthesiologist in
pre-opertive period
Dr.ahmed turkistani
Department of anesthesia
Professor& chairman
King saud university
:Objectives
To understand the perioperative period
term.
To understand the objectives of
preoprative visit.
To identify the risk factors in anesthesia.
To identify the lab tests needed before
surgery.
Stages of the Peri-Operative
Period
Pre-Operative

From time of
decision to have
surgery until
admitted into the
OR theatre.
Stages of the Peri-Operative
Period
Intra-Operative

Time from entering

the OR theatre to
entering the
Recovering Room
or Post Anesthetic
Care Unit (PACU)
Stages of the Peri-Operative
Period
Post-Operative

Time from leaving

the RR or PACU
until time of
follow-up
evaluation (often
as out-patient)
Preoperative visit.
To educate about anesthesia , perioperative
care and pain management to reduce
anxiety.
To obtain patient's medical history and

physical examination .
To determine which lab test or further

medical consultation are needed .

To choose care plan guided by patient's

choice and risk factors

 Benefits from surgery Risk of complications
:Preoperative Evaluation
A thorough history and physical exam.
Complete review of systems.

Organ specific issues.

Functional Status.
Habits (smoking, alcohol, drugs).
Medications (herbals) and allergies.
Anesthesia history.
Pre-op labs: one size does not fit all.
Patient related risk factors
(pulmonary)

Age
Obesity
Smoking
General health status
Chronic obstructive pulmonary disease

(COPD)
Asthma
Smoking
Important risk factor
Smoking history of 40 pack years or more

risk of pulmonary complications

stopped smoking < 2 months : stopped for

> 2 months 4:1(57% : 14.5%)

quit smoking > 6 months : never smoked

= 1:1 (11.9% : 11%)

Risk Stratification
Revised Cardiac Risk Index
High risk surgery (vascular, thoracic)
Ischemic heart disease
Congestive heart failure
Cerebrovascular disease
Insulin therapy for diabetes
Creatinine >2.0mg/dL
Active Cardiac Conditions
Unstable coronary syndromes
Unstable or severe angina
Recent MI
Decompensated HF
Significant arrhythmias
Severe valvular disease
Minor Cardiac Predictors
Advanced age (>70)
Abnormal ECG

LV hypertrophy
LBBB
ST-T abnormalities
Rhythm other than sinus
Uncontrolled systemic hypertension
Surgical Risk Stratification
High Risk
Vascular (aortic and major vascular)
Intermediate Risk
Intraperitoneal and intrathoracic, carotid, head
and neck, orthopedic, prostate
Low Risk
Endoscopic, superficial procedures, cataract,
breast, ambulatory surgery
Risk Stratification
ASA physical status
ASA 1 Healthy patient without organic
biochemical or psychiatric disease.
ASA 2- A Patient with mild systemic disease. No
significant impact on daily activity. Unlikely
impact on anesthesia and surgery.
ASA 3- Significant or severe systemic disease that
limits normal activity. Significant impact on daily
activity. Likely impact on anesthesia and surgery.
Risk Stratification
ASA 4- Severe disease that is a constant
threat to life or requires intensive therapy.
Serious limitation of daily activity.
ASA 5- Moribund patient who is equally
likely to die in the next 24 hours with or
without surgery.
ASA 6- Brain-dead organ donor
E added to the classifications indicates
emergency surgery.
Step #1:Is the surgery
?emergent

yes
?Is the surgery emergent *Operating room
no

(Next Step)

Consider beta-blockade, pain control

and other peri-operative management
Step 2: Determine Presence of
Active Cardiac Conditions
If none are present, proceed with surgery
Presence of one of these delays surgery for
evaluation
Many patients need a cardiac cath
Step 2
Unstable coronary syndromes

Decompensated heart failure

Significant arrhythmias

Severe valvular disease

Step #2: Active Cardiac
Conditions

yes Evaluate and treat per

Active Cardiac conditions current guidelines

no

Consider Operating Room

(Next Step)
?Step 3: Surgery Low Risk
Low risk surgery includes:
1. Endoscopic procedures
2. Superficial procedures
3. Cataract surgery
4. Breast surgery
5. Ambulatory surgery
Cardiac risk <1%
Testing does not change management
Step #3: Surgery Low
?Risk
Low risk surgery yes Operating room

No

(Next Step)
Airway Evaluation
Take very seriously
history of prior difficulty
Head and neck
movement (extension)
Alignment of oral,
pharyngeal, laryngeal
axes
Cervical spine arthritis or
trauma, burn, radiation,
tumor, infection,
scleroderma, short and
thick neck
 Airway Evaluation
Jaw Movement
Both inter-incisor gap
and anterior
subluxation
<3.5cm inter-incisor
gap concerning
Inability to sublux lower
incisors beyond upper
incisors
Receding mandible
Protruding Maxillary

Incisors (buck teeth)

Airway Evaluation
Oropharyngeal visualization
Mallampati Score
Sitting position, protrude tongue, dont say

AHH
Preoperative Testing
Routine preoperative testing should not be
ordered.
Preoperative testing should be performed

on a selective basis for purposes of guiding

or optimizing perioperative management.
Preoperative Testing5
Procedure based.
Low risk
Baseline creatinine if procedure involves contrast
dye.
Intermediate risk
Base line creatinine if contrast dye or >55yr of age.
High risk
CBC, lytes & S, creatinine as above.
PFTs for lung reduction surgery.
Preoperative Testing
Disease-based indications
Alcohol abuse
CBC, ECG, lytes, LFTs, PT
Anemia
CBC
Bleeding disorder
CBC, LFTs, PT, PTT
Cardiovascular
CBC, creatinine, CXR, ECG, lytes
Preoperative Testing
Disease-based indications
Cerebrovascular disease
Creatinine, glucose, ECG
Diabetes
Creatinine, electrolytes, glucose, ECG
Hepatic disease
CBC, creatinine, lytes, LFTs, PT
Malignancy
CBC, CXR
Preoperative Testing
Disease-based indications
Pregnancy (controversial)
Serum B-hCG- 7 days, Upreg 3 days
Pulmonary disease
CBC, ECG, CXR
Renal disease
CBC, Cr, lytes, ECG
RA
CBC, ECG, CXR, C-spine (atlantoaxial subluxation)
AP C-spine, AP odontoid view and lateral flexion and
extention.
Preoperative Testing
Disease-based
Sleep apnea
CBC, ECG
Smoking >40 pack year
CBC, ECG, CXR
Systemic Lupus
Cr, ECG, CXR
Preoperative Testing
Therapy-based indications
Radiation therapy
CBC, ECG, CXR
Warfarin
PT
Digoxin
Lytes, ECG, Dig level
Diuretics
Cr, lytes, ECG
Steroids
Glucose, ECG
Q& A