PRE ANAESTHETIC

ASSESSEMENT & EVALUATION

Dr.G.VIJAYA .MD
• What are the goals of pre op evaluation?
• Pre op risk assessment-ASA classification
• History
• General examination
• Assessment of functional capacity of the pt
• Airway assessment
Assessment for mask ventilation
Assessment for laryngoscopy/intubation
• Evaluation of co existing disease
CVS,RS,LIVER ,RENAL DISORDER
HEMATOLOGY,ENDOCRINE,CNS&
MUSCULOSKELETAL DISORDER
GOALS

• To obtain pertinent information regarding patients

current & past medical history
• To formulate an assessment of the patient’s intra
operative risk
• To decrease surgical morbidity
• To minimize expensive delays
• Avoid cancellations on the day of surgery
• To increase the peri operative efficiency
 PRE OP RISK ASSESSEMENT
ASA PHYSICAL STATUS classification
(1941 by Meyer Saklad )
Healthy pt without organic ,biochemical or psychiatric disease
ASA 1

Pt with mild systemic disease (eg. mild asthma or well controlled HT)
ASA 2 No significant impact on daily activity
Unlikely to have impact on surgery or anesthesia
Significant severe systemic disease that limits normal activity (renal
failure on dialysis or class II CCF)
ASA 3
Significant impact on daily activity /probable impact on surgery or
anesthesia
Severe disease that is constant threat to life or requires intensive therapy
ASA 4 (eg acute MI, respiratory failure)serious limitation of daily activity
(major impact on surgery or anesthesia)
Moribund pt who is equally likely to die in next 24 hrs with or without
ASA 5
surgery
ASA 6 Brain dead organ donor
E – PRE FIXED FOR EMERGENCY TILL ASA 4 (ASA 4 E)
• History And Physical
examination Are The
Most Important
Assessors Of Disease
And Risk
 PRESENTING COMPLAINT

Why does the patient need an operation now?

• Is it acute/chronic illness?
• Presenting symptoms?
e.g. anaemia, cachexia, pain, seizures etc
• What are the pathophysiological consequences?
e.g. thyroid mass
– Local - stridor, SVC obstruction
– Systemic - hypo/hyperthyroidism
ASSOCIATED MEDICAL CONDITIONS
Given the presenting problems are there any
other conditions I am worried the patient
could have?

• Bowel ca. - liver mets with abnormal LFTs,

abnormal coagulation, impaired drug
metabolism
• Peripheral vascular disease - IHD, carotid
disease, HT, renal disease, COAD
OTHER MEDICAL CONDITIONS

Any other problems that may affect

perioperative morbidity and mortality?

• cardiac disease
• respiratory disease
• arthritis
• endocrine disease - diabetes, obesity etc
• Heart burn/reflex disease
FUNCTIONAL CAPACITY

• MET-metabolic equivalent of task

• 1 MET Can you dress yourself?

• 4 MET Can you climb a flight of stairs?

• 10 MET Can you participate in strenuous

activities (swimming,
tennis,football)
 FUNCTIONAL CAPACITY
MET Functional Level Of Exercises
1 Eating.,Working At Computer, Dressing
2 Walking Downstairs ,Cooking
3 Walking 1-2 Blocks
4 Raking Leaves, Gardening
Climbing 1 Flight Of Stairs(20steps Of 6 Inches Ht),
5
Dancing,bicycling
6 Playing Golf, Carrying Clubs
7 Playing 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 Basket Ball
12 Running Rapidly For Moderate To Long Distance
 GENERAL
HISTORY/ASSESSMENT
• Family history
• Previous anaesthetics
– PONV
– allergy
– malignant hyperpyrexia
– difficult airway
– difficult IV access
Rule out obstructive sleep apnea

HISTORY OF
• Snoring
• Day time sleepiness
• Hypertension
• Obesity

• Large neck circumference (>17 inches in

men , >16 inches in women)
 DRUG HISTORY
Very useful, often forgotten
• Current medications
• ALLERGY
• Medic alert bracelets
• Smoking/alcohol history
• Other drugs of abuse!
PHYSICAL EXAMINATION
• HR,RR,BP,SPO2,
• Height,wt,BMI
• CVS
PULSE VOLUME ,RHYTHM ,
Auscultate for murmurs, signs of volume over
load
S3/S4
JVP, ascites , pedal edema
• RS
wheezing
Decrased breath sounds
Abnormal breath sounds
Cyanosis/clubbing
Use of accessory muscles
Effort of breathing
 AIRWAY ASSESSMENT
• History –Prev surgery,anesthesia
• Congenital airway difficulties- pierre robin
syndrome,klippel feil syn, down synd etc
• Acquired –rheumatoid arthritis , still’s
disease,ankylosing spondylitis,
acromegaly,pregnancy , diabetes
• Iatrogenic- surgery on TMJ, cervical spine
fusion, oropharyngeal readio therapy,laryngeal
surgery
 EXAMINATION

• Small mouth , receding chin,high arched

palate,large tongue,obesity ,large breasts
• Head . Neck burns,tumors,abscess,restrictive
scars
• Loose teeth, protruding teeth,dentures
 ASSESSMENT IN RELATION TO
MASK VENTILATION
• MOANS
• M-mask seal –difficult
• BONES
in receding
• B-bearded individual mandible,facial
• O-obesity anomalies
• N-no teeth • O-obesity
• E-elderly • A-advanced age
• S-snorer • N-no teeth
• S-snorer
• MALLAMPATTI
GRADING
• Original – 3 classifiaction
• Samson & Young’s
Modification
Have 4 Classifications
 MALLAMPATTI CLASSIFICATION
• Have patient sit up, and stick out tongue without
phonating
• May be unable to properly assess this in an
emergent field situation
• Performed with patient in a sitting position, head
neutral, mouth open wide and tongue protruding
to the maximum
• RELATES TO TONGUE SIZE TO
PHARYNGEAL SIZE
MALLAMPATTI CLASSIFICATION
 INTER INCISORS GAP

• 4.6 cm or more – normal –easy insertion of

laryngoscope blade
• <3 cm – difficulty in intubation
• < 2.5 cm – LMA insertion difficult
 PROTRUSION OF MANDIBLE

• Class A – able to protrude lower incisors

anterior to the upper incisors
• Class B – lower incisors can just reacjh the
margin of upper incisors
• Class C –lower incisors cannot protrude to the
upper incisors

• Class B & C –difficult laryngoscopy

 THYROMENTAL DISTANCE
(PATIL TEST)

• Distance from tip of thyroid cartilage to tip of

mandible (neck fully extended)
• >7 cm –normal
• <6cm -75% difficult laryngoscopy
STERNOMENTAL DISTANCE
(SAAVA TEST)

Distance from upper border of the manubrium to

the tip of mandible (neck fully extended,mouth
closed)

• <12.5 cm –difficulty intubation

 CERVICAL & ATLANTO
OCCIPITAL JOINT FUNCTION
• Intubation position-early morning sniffing /
magill’s position
• Ask the pt to touch his manubrium sterni with
chin – assures flexion of 25-30 °
• Ask the pt to loof at ceiling with out raising eye
brows to test AO joint(well extension 85°)
• If 2/3 rd or complete reduction of extension at
AO joint –difficult laryngoscopy
 DELILKAN TEST
• Ask the pt to sit in neutral position/you stand
behind the pt
• Place your index finger of left hand under chin
• Index finger of right hand on occipital tuberosity
• Ask the pt to look ceiling
• If left index finger higher than right-normal
• If both are in same level –moderate limited
mobilty
• If left is below than right –severe limitation
Evaluation of co existing diseases
 CVS

• Rule out HT-(if 2 or more readings >140/90mmhg)

• Causes-essential / pheochromocytoma/
hyperthyroidism/ coccaine,amphetamines
• Post pone if BP >200/115mmhg
• Drug history-diuretics,digoxin,calcium channel
blockers,beta blockers,ACEI etc
GOLDMAN CARDIAC RISK
INDEX FOR NON CARDIAC
SURGERY
GOLDMAN CARDIAC RISK
INDEX FOR NON CARDIAC
SURGERY
REVISED CARDIAC RISK INDEX
• High risk surgery (intra peritoneal ,
Intrthoracic,suprainguinal
vascular surgeries)
• IHD
• H/O congestive heart failure
• H/O CVA
• Diabetes mellitus on insulin
• Creatinine >2.0mg/dl
 INVESTIGATIONS

• ECG – recent q waves, conduction

abnormailities,arrythmias
• Normal ECG –doesn’t exclude cardiac disease
• Echo cardiogram
• Angio gram – if needed (to know shunt fraction ,left
atrial pressure etc )
 CARDIAC EVALUATION FOR NON
CARDIAC SURGERY
Step1: Proceed to surgery with medical
EMERGENCY risk reduction & perioperative
SURGERY surveillence

STEP 2:ACTIVE CARDIAC CONDITIONS

•UNSTABLE ANGINA /RECENT MI POST PONE SURGERY
•DECOMPENSATED HEART FAILURE UNTIL STABILISED OR
•SIGNIFICANT ARRHYTHMIAS CORRECTED
•SEVERE VALVULAR HEART DISEASES
Step 3: low risk surgery Proceed to surgery
•Superficial or endoscopic
•Cataract/breast
•Ambulatory

Step 4-functional
Proceed to surgery
capacity
Good >4 mets

No clinical Proceed to surgery

Step5:clinical
predictors predictors
•IHD Proceed to surgery
•Compensated with HR
Vascular
heart failure 1-2 control/consider non
/intermediat
•CVA predictors invasive testing if it
esurgery
•DM will change
•Renal management
insufficiency
>3 Vascular consider testing if it
predictors surgery will change
management
 RS

• H/O SMOKING
• RULE OUT BRONCHIAL ASTHMA
• RULE OUT COPD
• EVALUATE FOR RESTRICTIVE LUNG
DISEASE
• RULE OUT PULMONARY HYPERTENSION
 PULMONARY DISORDER
EVALUATION

• SIMPLE CHEST X RAY PA VIEW

• PFT – IF NEEDED
(in case of thoracic surgery,bronchial asthma
,copd pt,if pt posted fot kyphoscoliosis
correction)
• BED SIDE PULMONARY FUNCTION TESTS
• ABG –IF NEEDED
 BREATH HOLDING
(SABRASEZ)TEST

• Pt asked to take deep breath and hold it for as

long as possible
• >30 sec –normal
• <15 sec-reduced vital capacity
• Normal person – hold up to 1 min
SNIDERS MATCH BLOWING
TEST

• Lighted match stick held at 6 inches (15 cm ) from

pt mouth
• Pt asked to blow out the match with out pursing lips
• Rough estimate of exp capacity /MBC
• If cant –MBC <60 L/MIN OR FEV1 <1.6L
• IF NOT ON 8 CMS DISTANCE –FEV 1<1L
 Risk factors for pulmonary
complications

• H/O smoking
• ASA >2 GRADE
• AGE >70 yrs
• COPD
• Neck ,thoracic,upper abdominal surgery,neuro surgery
• >2 hrs procedures
• Albumin <3 gm/dl
• Exercise capacity <1 flight
• BMI>30
HEPATOBILIARY DISORDER

• H/o-hepatitis-alcoholic,viral
• Obstructive /hemolyric jaundice
• Cirrhosis
• Portal hypertension
• Hepatic encephalopathy
• Wilson’s disease
• Hemochomatosis
• Hepato cellular carcinoma/secondaries
• LFT
• USG
• COAGULATION PROFILE
• SERUM PROTEINS
 PUGH‘S MODIFICATION OF CHILD
GRADING-chronic liver disease
Clinical & Biochemical POINTS SCORED
variables 1 2 3
Serum albumin (g/L) >35 28-35 <28

Serum bilirubin (µmol/L) <35 35-60 >60

[Mg /dl] < 2 2 -3 >3
PT (seconds) prolonged 1-4 4-10 10

from control INR [ < 1 .7] INR [1.7 INR >2.3

-2.3]
Ascites None Mild Moderate

Encephalopathy Absent Grade I – Grade III –

II IV
 RENAL DISORDER

• Cause of renal failure-hypertension.diabetes

• Cardiovascular complications+
• Electrolyte imbalance
• Acute or chronic renal failure
• Associated coagulopathy due to platelet
dysfunction
• Anemia due to decreased erythropoetin
prodution
• Renal function tests
• HB/ Hematocrit
• Platelet count
• Coagulation profile
• Creatinine clearence (24 hrs)
• ABG
 Pre Renal Vs Intrinsic Renal ARF
Prerenal Intrinsic Renal
Diagnostic Index
Azotemia Azotemia

Fractional excretion of sodium (%)a

<1 >1
•UNa x PCr/PNa x UCr x 100
Urine sodium concentration (mmol/L) < 10 >20
Urine creatinine to plasma creatinine ratio >40 >20
Urine urea nitrogen to plasma urea nitrogen ratio >8 <3
Urine specific gravity >1.018 < 1.015
Urine osmolality (mosmol/kg H2O) >500 < 300
Plasma BUN/creatinine ratio >20 < 10-15
Renal failure index
<1 >1
•UNa/UCr/PCr

Muddy brown
Urinary sediment Hyaline casts
granular casts
 CREATININE CLEARENCE

• COCKCROFT –GAULT formula

Creatinine clearance = (140-age ) × wt (kg)
×(0.85 if female)
72 ×serum creatinine (mg/dl)
ENDOCRINE DOSORDER-
DIABETES MELLITUS

• Duration
• oral hypoglycemic drugs,insulin
• Rule out micro & macro vascular /end organ
damage
• Diabetic nephropathy
• Silent ischemia
• Autonomic neuropathy-orthostatic
hypotension(>20/10mmhg difference)
• Stiff joint syndrome –difficult intubation
• Fasting blood glucose to be <110mg/dl
• FBS,PPBS
• HB A1C(<7% CARRYS LOW RISK)
• URINE ACETONES
• RFT, ELECTOLYTES
• ECG
• ECHO
 ENDOCRINE-THYROID
• Hyper /hypo thyroidism
• Rule out pericardial effusion ,myxoedema-
hypothyroidism
• palpitations, tachycardia
• Arrhythmia-hyperthyroidism
• Ask for anti thyroid,betablockers,steroids
• Eltroxin
• Thyroid function test
• Clinically symptoms /signs - should be
improved
• ENT opinion to rule out pre existing vocal
cord palsy
• X ray neck – to rule out tracheal
compression
 OTHER ENDOCRINES

• Parathyroid –hyper or hypo calcemia

• Adrenal insufficiency –due to HIV/TB
• Multiple endocrine neoplasia(MEN
syndrome ) to be ruled out
• Pheocromocytoma
 CNS

• CVA
• Seizure disorder-treatment/drugs
• Multiple sclerosis
• Cerebral aneurysms
• Neuromusculat junctions disorder
• Muscular dystrophies/myopathies-prone for malignant
hyperthermia.neurolept malignant syndrome
• Intracranial tumours-relative C/I to central neuroxial
block
 HEMATOLOGY
• Anemia
• Target >10gm/dl for normal pt
• Desire pre op /intra op blood transfusion
• Rule out Jehovah Witnesses

Increased mortality/morbidity below

Condition
hemoglobin (g/100 ml)

Old age <11 g/100 ml

Heart valve operation <12 g/100 ml

Heart failure <11 g/100 ml

PTCA <10 g/100 ml

COPD <13 g/100 ml

 HEMATOLOGY –RULE OUT IF
SUSPECTED

• Sickle cell disease

• Coagulopathies
• Hemophilias
• Von willibrands disease
• Thrombocytopenia
• Thrombocytosis
• Polycythemia –risk of thrombosis
 MUSCULO SKELETAL

• Rheumatoid arthritis,ankylosing spondylitis

• SLE
• Kyphoscoleosis

• All these can complicate in difficult

intubation/difficulty in regional block
• Associated cardiovascular/pulmonary
dysfunction will be there
 RULE OUT

• Malignancy-metastasis /complications
• Transplanted organ –sepsis/steroids
/chemotherapy
• Obesity/OSA
• HIV
• Drug abuse
• H/O pseudo cholinesterase deficiency
• H/O malignant hyperthermia
ASSESSMENT IN PEDIATRICS

• Airway assessment not reliable

• H/O-freq URI/LRI or snoring-indicate
obstructed airways
• Rule our adenoid/tonsillar enlagement
• Cheat indrawing –indicate lower airway
obstruction
• Go thro prev records/anesthesia charts
• Assess for IV line accessebilty
 PRE OP ADVICE

• Risk the pt according to ASA grade

• Advice to continue all the drugs except
anti coagulants,OHA
• Switch over to regular insulin
• Continue steroids
• Pre medications to be advised
• Blood requirements
• Clotting time ,bleeding time not at all
reliable
 CURRENT IE PROPHYLAXIS
AHA 2007 RECOMMENDATIONS

• Prosthetic valves
• Prev IE
• CONGENITAL HEART DISEASE
1.Unrepaired Cyanotic Heart Disease including
palliative shunt/conduits
2.Compltely repaired CHD with prosthetic material
3.Repaired CHD with residual defects
4.Cardiac transplantation receipients
 CURRENT RECOMMENDATIONS FOR
ANTICOAGULATION AND CENTRAL NEUROXIAL
BLOCK
RECOMMENDATIONS LABORATORY

ANTIPLATELETS ASPIRIN/NSAIDS NONE NONE

TICLOPIDINE STOP 14 DAYS PRIOR NONE

CLOPIDOGREL 7 DAYS PRIOR NONE

ABCIXIMAB/EPTIFI
AVOID NEUROXIAL
BATIDE/TIROFIBA
BLOC
N
STOP 4-5 DAYS PRIOR
PT/INR BEFORE
MONITOR FOR 24
AND AFTER
HRS AFTER
ANTICOAGULATNS WARFARIN NEUROXIAL
REMOVAL OF
BLOCK
EPIDURAL
INR TO BE <1.5
CATHETER
 RECOMMENDATIONS LABORATORY

>4 DAYS –
IF ON SUB CUT
HEPARIN DELAY UNTIL BLOCK CHECK
HEPARIN
PLATELETES
DELAY UNTIL 1 HR
AFTER BLOCK
IV HEPARIN REMOVE CATHETER DO PTT
AFTER 2-4 HRS OF
LAST DOSE
PRE OP – BLOCK
AFTER 12 HRS OF
LAST DOSE (DELAY 24
HRS IF HIGH DOSE
LMWH THE PT GIVEN)
REMOVE 12 HRS
AFTER LAST DOSE
AND WAIT 2 HRS TILL
NEXT DOSE
 TO CONCLUDE

• Discuss and explain the pt about anesthetic

technique
• Explain the risk
• Discuss with surgeon if needed
• Plan well about the anesthetic technique and
reduce the morbidity and mortality during intra
op as well in the post op period also
 REFERENCES

• MILLER 7 TH EDITION
• OXFORD HAND BOOK
• RASHID KHAN –AIRWAY MANAGEMENT
THANK YOU