Pre-operative assessment by aah15699


      Dr Doug Campbell
  Division of Anesthesiology
       February 3rd 2006
Goals of preoperative assessment

• History and physical examination to
  determine relevant tests and consultations
• Guided by patient choice and medical risk
  factors choose a plan of care
• Informed consent
• Educate patient about anaesthesia, pain
  management and perioperative care
• Reduce patient care costs

What is the risk of proceeding versus the
benefit to the patient?

Can we modify these risks before surgery?
Mortality related to anaesthesia

• Approx 1:26,000 anaesthetics
• One third of deaths are preventable
• Causes in order of frequency
  – inadequate patient preparation
  – inadequate postoperative management
  – wrong choice of anaesthetic technique
  – inadequate crisis management
Risk and ASA classification
History and
physical 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
What is the patients functional capacity?
Functional capacity

• 1 MET Can you dress yourself?

• 4 MET Can you climb a flight of stairs?

• 10 MET Can you participate in strenuous
         activities (swimming,
Anaesthetic history/assessment

• Family history
• Previous anaesthetics
   – PONV
   – allergy
   – malignant hyperpyrexia
   – difficult airway
   – difficult IV access
Airway assessment

Best done by an anaesthetist
Certain features of concern
  – small mouth
  – poor dentition
  – limited neck mobility
  – scars/surgery/anatomical abnormalities
  – obesity
Mallampati scoring system
Why would this man’s airway
be difficult to manage?
Drug history

Very useful, often forgotten
• Current medications
• Medic alert bracelets
• Smoking/alcohol history
• Other drugs of abuse!
“The more tests, the better”
Perioperative medications

• Take all usual medications
   – Antihypertensives
   – Beta blockers
   – Statins

• Think about discontinuing/replacing
   – Aspirin
   – Anticoagulants
   – Diabetic medications
   – MAOIs

• History and physical most important assessors
  of disease and risk
• ASA and functional status good predictors of
• Lab tests have some usefulness
   – add little in low risk patients
   – may add false + ves
   – add expense
    Case example

You are an orthopaedic House Surgeon
Your Registrar tells you

“ There is a fractured femur in ED, get it ready
  for theatre.”

What are you going to do?
   Case example

A 49 yr old Samoan woman presents for
elective hemicolectomy. She has a 10 yr
history of NIDDM . She takes glipizide
and metformin

What are you going to do?
Case example

An 81 yr old man presents for elective
TURP. He has atrial fibrillation, has had
previous TIAs and is on warfarin.

What are you going to do?
Case example

A 76 year old man with PVD presents for
femoro-popliteal bypass surgery. He has
an ejection systolic murmur on

What are you going to do?

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