Preoperative Period – Dr.
Mariano
“The safe conduct of anesthesia requires A history and physical examination, focusing
meticulous preoperative assessment, on risk factors for cardiac, pulmonary and
preparation and planning.” infectious complications, and a determination
of a patient’s functional capacity, are essential
Perioperative Period: 3 Major Phases of to any preoperative evaluation.
Surgery
Preoperative period In addition, the type of surgery influences the
Decision to be operated until the start overall perioperative risk and the need for
of surgery further cardiac evaluation.
Intraoperative period
Surgery itself Routine laboratory studies are rarely helpful
Postoperative period except to monitor known disease states.
After surgery until recovery is
complete Preoperative Basic Health Assessment
A complete preoperative basic health
“All patients must receive a preoperative assessment includes:
anesthetic evaluation.” Medical History
Indications for surgical procedure
Preoperative Period: Safe Conduct of Allergies and intolerances to medications,
Anesthesia anesthesia or other agents (specify
Evaluation reaction type)
History Known medical problems
Physical examination Surgical history
Laboratory evaluation Trauma (major)
Risk assessment Current medications (prescription, OTC
Preparation for Anesthesia medications, herbal and dietary
Preoperative fasting supplements and other drugs)
Patient education Focused review of issues pertinent to the
Pain management planned anesthesia and procedure
Patient responsibilities Current status of pertinent known
Premedication medical problems
Intravenous fluid Cardiac status
Management of concurrent diseases Pulmonary status
Planning Functional status
Anesthetic plan Hemostasis status (personal or family
history of abnormal bleeding)
Preoperative Evaluation Possibility of severe (symptomatic)
Gathering information about the patient anemia
and formulating an anesthetic plan
Physical examination
Goals Vital signs
To reduce patient risk and morbidity Weight and height
associated with surgery and coexisting Airway
diseases Heart
To promote efficiency and reduce cost Lungs
To prepare patient medically and Extremities
psychologically for surgery and anesthesia Neurological examination
Other systems appearing affected by
Recognition history
History
Physical examination Laboratory Evaluation
Laboratory evaluation It should be selective and individualized.
Common Causes of Anesthetic Complications Hematocrit or Hemoglobin Concentration
Inadequate preoperative planning All menstruating women
Errors in patient preparation All patients over 60 years
All patients who are likely to
experience significant blood loss and
may require transfusion
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Preoperative Period – Dr. Mariano
Serum glucose and creatinine Pulmonary disease
ECG and chest x-ray Chest radiographs, hemoglobin, glucose
(age >=45 years)
Labororatory Exam Validity ECG (age >40 years)
Hematocrit 1 month Provide patient with instructions for
Serum glucose / creatinine/ BUN 1 month incentive spirometry, deep-breathing
Liver function test 1 month exercises
ECG 6 months Abdominal or thoracic surgery
Chest x-rays 6 months Provide patient with with instructions
Coagulation studies 1 week for incentive spirometry, deep-
breathing exercises
Coagulation studies would be indicated: Malnutrition
If the patient is receiving anticoagulant Laboratory tests based on primary
therapy disease plus albumin and lymphocyte
Family or personal history that suggests a count.
bleeding disorder If malnutrition is severe consider
Evidence of liver disease postponing surgery and providing
preoperative supplementation.
A urine pregnancy test should be considered
for women of childbearing age. Categorize
Risk Assessment
Chest X-ray It is detection of pre-, intra-, and
American College of Radiology postoperative risk factors which increase
Does not recommend routine pre- mortality and morbidity.
operative chest x-ray in healthy ASA physical status classification
patients without co-morbidities Other system assessment
Conclusion CVS (Goldman’s index)
Preoperative chest x-rays result in few Respiratory assessment
changes to patient management in the CNS assessment
absence of risk factors among patients Renal and liver disease assessment
under 70 years old.
ASA Physical Status Classification
Patients who warrant a second examination Class Definition Mortality
just before hospitalization: Rate
Patients with cardiopulmonary disease 1 A normal healthy patient 0.06 –
Child with URTI 0.08%
to assess the current status of the 2 A patient with mild 0.27 –
infection systemic disease and no 0.4%
to postpone the procedure if persistent functional limitation
fever, wheezing or significant nasal 3 Moderate to severe 1.8 –
discharge systemic disease that result 4.3%
in some functional
limitation.
Summary of Recommended Laboratory Work- 4 Severe systemic disease 7.8 -
ups Depending in History and Physical that is a constant threat to 23%
Examination: life and functionally
Healthy patient </= 40 years incapacitating.
Hemoglobin 5 A patient who is not 9.4 –
Urine screening for pregnant women of expected to survive 24 51%
childbearing potential hours with or without
Healthy patient >40 years surgery.
Add ECG and blood glucose (age 6 A brain dead patient whose
>/=45) organs are being harvested.
Cardiovascular disease E If the procedure is an
ECG, chest radiographs, hemoglobin, emergency, the physical
electrolytes, BUN, creatinine, glucose status is followed by “E”
(age > = 45 years or history of
diabetes)
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Preoperative Period – Dr. Mariano
Goldmann Index
In 1977, Goldmann, et.al., developed the 1st
cardiac risk index for patients >40 years
of age about to be operated by looking at
nine variables.
Preop, 3rd heart sound or jugular
venous distention
Myocardial infarction in the preceding
6 months
>5PVCs/minute
Cardiac rhythm other than NSR or
PACs
>70 years
Intraperitoneal, intrathoracic or aortic
operation
Emergency operation
Important aortic valvular stenosis
Poor general medical condition
Surgery-Related Predictors for Risk of
Perioperative Cardiac Complication
High risk
Emergency surgery
Anticipated increased
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