[ANESTHESIOLOGY] Preanesthetic Evaluation

Lecturer: Abigail Luna-Gomez MD

Transcriber: Patrick Angelo R. Bautista August 2020


References and Legends
nd II. PATIENT’S PERTINENT HISTORY
• {💻} PPT and {📕} Chapter 1 - Anesthesiology Manual 2 Ed
• The first component of the Preoperative Evaluation of the patient is
• {📖} Miller’s Anesthesia 8 Ed
th
that patient’s pertinent history.
• {📌} Transcriber’s Note
• The anesthesiologist selects all of the vital medical conditions
Table of Contents (previous or present, acute or chronic, and treated or untreated)
I. Preanesthesia Evaluation 1 that will have significant effects on the anesthetic management.
II. Patient’s Pertinent History 1 • This is an essential part of the evaluation that reduces
III. Preoperative Physical Examination for Anesthesia 3 perioperative morbidity or mortality significantly.
IV. The Anesthetic Plan 4 • The healthcare provider has the opportunity to think and watch out
V. Conclusion of Preoperative Anesthetic Visit 5 for all of the possible events or complications that may arise during
perioperative period, and to prepare necessary interventions
should these problems come.

Parts of the Patient’s Pertinent History

1. History of Present Surgical Illness

• Brief description of initial symptoms leading to the surgical consult
• Diagnostic tests done
• Surgical evaluation and presumptive diagnosis
📌 Scan the QR Code for the video lecture. • Initial treatments and outcomes
Note: You can use this only if you’re logged in to your FEU-NRMF Moodle
• Any changes or significant trends in the vital signs
account and have access to the Anesthesiology Course. • Significant fluid status and management of the patient

2. Co-existing Medical Illness

I. PREANESTHESIA EVALUATION
• This covers all of the co-existing medical conditions of the patient
Importance of Anesthetic Evaluation
using the systemic “Organ System Approach”
• Patient Safety
• Co-existing cardiac, pulmonary, renal, hepatic, endocrine or
• Provider Safety
infectious diseases should be given importance.
American Society of Anesthesiologists (ASA) Task Force Definition:
• Systematic process of clinical assessment by the anesthesiologist
3. Medication History
that precedes the delivery of anesthesia care for surgery and for • Current medications taken by the patient and these includes:
non-surgical procedures. 9 Anti-hypertensives
• This applies to all ages who will undergo surgery requiring: 9 Anti-anginas
9 General anesthesia 9 Anti-arrhythmics
9 Regional anesthesia 9 Anti-coagulants
9 Monitored anesthesia care 9 Anti-convulsants
• Visit is usually done before the day of surgery. 9 Endocrine maintenance medications
• Patient interview during preanesthetic evaluation includes: • Supplements and other herbal medicines are also noted as some
9 Obtaining informed consent of these may have effects on coagulation, autonomic, liver and
9 Educating the patient kidney functions.
9 Enlightening the possible anesthesia risks and complications of
the anesthetic plan 4. Allergies and Drug Reactions
• It also reveals the patient’s current state of health as well as the • These are the unusual, unexpected or unpleasant reactions to
patient’s previous medical or surgical problems. perioperative medications.
• Information gathered in the history and PE will be combined with • These reactions are not that rare and may give rise to complications.
the needs of the particular surgical procedure to come up with a • Patients with history of overt allergic reaction will volunteer the
safe and effective delivery of anesthetic plan. information to the anesthesiologist.
• For instance, a proper patient and personnel safety equipment • It may be prudent to run down all of the drugs or substances that
should be given to cases involving highly communicable diseases. will be used intraoperatively that the patient may have missed.
• In this aspect, the preanesthetic evaluation therefore significantly 9 Latex from the gloves
improves the safety of both the patient and healthcare providers. 9 Medical tapes / adhesives
• Overall, the primary goal of preanesthetic evaluation is: 9 10% Iodine
9 To reduce the patient’s surgical and anesthetic morbidity and • True allergic reactions
mortality 9 Observed when an administered agent (described by the
patient, documented in the medical chart or observed directly)
leads to systemic manifestations such as:
§ Pruritus, hives, facial or oral swelling
§ Shortness of breath, difficulty of breathing, wheezing
§ Vascular collapse

5. Anesthesia Exposure
• The anesthesiologist focuses on the specifics of anesthesia.
📌 Scan the QR Code: Preanesthesia Evaluation sample • The patient is asked for previous to anesthesia whether general or
regional for any previous procedures and the corresponding
reactions and complications if any.
• Since patients under general anesthesia are unconscious and may
not be aware of other vital information, obtaining information from
different helpful sources such as:
9 Previous anesthetic records
9 History from attending physicians / family members / relatives

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5.1 Previous Anesthesia Records Marijuana

• The anesthesia record presents an overview of the patient’s • Most popular recreational drug from the plant of Cannabis sativa.
condition during the intraoperative event. • A hallucinogenic agent that can be smoked or be taken orally.
• Aside from the vital signs of the patient, fluid balance • If this is combined with anesthetic drug like diazepam, it increases
management, interventions, type of anesthesia technique used, the sedative effect that enhance the depression of CNS.
manner of induction and complications are shown in detail. • In addition, it also affects the cardiovascular system which also
• Medical records that may help the current anesthesiologist in the enhances myocardial depression.
pre-anesthetic evaluation of the following: • Therefore, a potentiation drug interaction occurs between
9 Response to sedative / analgesic pre-medications and anesthetic agents and cannabinoids.
anesthetic agents
9 Note of difficulty of mask ventilation, the method of Cocaine
laryngoscopy used, the size and type of laryngoscope blade • AKA the “rock” (cracked cocaine), the most serious health
and endotracheal tube used concern worldwide extracted from the plant Erythroxylon coca.
9 Note of difficulty of needle insertion, the technique used during • It is extremely addictive that it can be smoked, injected, snorted
regional anesthesia and its outcome and ingested orally.
9 Note of difficulty of insertion / placement of vascular access • Cocaine interferes presynaptic uptake of sympathomimetic
and invasive monitoring neurotransmitters (norepinephrine, serotonin, dopamine) that
9 Perianesthetic complications causes a euphoria due to free catecholamines.
• However, a patient under regional anesthesia may have both:
9 Hypertension due to peripheral vasoconstriction
6. Family History
9 Hypotension which may lead to cardiac dysrhythmias or
• It is important to take note of adverse anesthetic reactions or myocardial dysfunction
outcomes among family members and relatives.
• This gives the anesthesiologist a chance to identify any familial Club drugs
disease that may arise from exposure to certain anesthetic agents • Such as Lysergic acid (LSD), Phencyclidine (PCP),
and make necessary preparations / interventions. 3,4-Methylenedioxmethamphetamine (MDMA) – Ecstasy
• “Has anyone in your family or relatives experienced unusual or • When taken orally, it causes:
serious reactions upon exposure to anesthesia” 9 Auditory, visual, tactile hallucinations
• The predisposition to have Malignant Hyperthermia (MH) is a 9 Distortions of body image, environment, reality
familial disease which is present in some parts of the Philippines. 9 Anxiety and a “fear of going crazy”
9 MH is a rare life-threatening anesthetic emergency with high • These drugs stimulate the sympathetic nervous system by causing
morbidity and mortality rates. increase in blood pressure, heart rate and body temperature.
9 It manifests upon exposure to triggering factors such as volatile • Overdose with these medications can cause seizures, respiratory
anesthetics and succinylcholine. depression, coma and eventually death.
• Patients scheduled for surgery with history of taking “club drugs”
7. Social History within 24 hours will likely have autonomic dysregulation.
9 Erratic swings of BP with increased HR
7.1 Perioperative Cigarette Smoking Risk 9 Predisposes the patient to the following:
• A study conducted by the American College of Surgeons National § Risk of cardiomyopathy
Surgical Quality Improvement Program (2011) found out that § Coronary and cerebral vasospasm
smokers had a higher mortality and increased rates of all types of
cardiorespiratory and septic complications. 8. Alcohol Abuse
• There is a strong association between smoking and major adverse • Alcohol abuse each have its own anesthetic implications.
surgical events that affects perioperative outcomes. • Obtaining an accurate history of alcohol aids to identify patients
• Cigarette, electronic cigarette (vape smoking) and tobacco: who have greatest risk for postoperative complications.
9 Nicotine • There is a great degree of unpredictability of effect of the
§ Targets the sympathetic nervous system that causes medications used in anesthesia for these patients even at clinical
hypertension and tachycardia. doses and should therefore be adjusted accordingly.
§ Impairs the ciliary motility, increases mucus production, • Example: Acute intoxication of alcohol
decrease clearing of secretions which makes the bronchial 9 The requirement for an IV anesthetic to put this patient to sleep
tree irritable will be less than a normal healthy patient.
9 Carbon monoxide
• Postoperative morbidity complications of alcohol abuse:
§ Displaces oxygen from the molecule of hemoglobin 9 Infection 9 Need of ventilatory support
producing a shift in the oxygen-dissociation curve to the left 9 Bleeding disorders 9 End-organ failure
which limits the oxygen availability to the tissues leading to
tissue ischemia.
9. NPO “Non Per Orem” Status / Last Oral Intake
• Other effects of smoking:
9 Weak immune function • Preoperative fasting
9 Delayed wound healing 9 Period of time before a surgery or a procedure when patients
9 Abnormal bone metabolism are advised not to take any oral intake of solids and liquids so
9 Direct effect on the CNS which disturbs the pain perception as to prevent perioperative pulmonary aspiration.
and opioid dose requirements • Perioperative pulmonary aspiration
• Last smoking history: 9 Presence of gastric contents in the lungs after induction of
9 Patient is advised to stop smoking 2 months (8 weeks) prior anesthesia, during procedure or surgery or immediate
to an elective procedure to minimize wound-related and post- postoperative period
operative cardiopulmonary complications. • The 6-8 hours on NPO is observed in anesthesia practice for all
patients undergoing anesthesia to allow sufficient time for gastric
7.2 Illicit Substance Abuse emptying to prevent aspiration during anesthesia.
• Can pose a threat upon exposure to anesthesia. • During induction of anesthesia, the patient is rendered
• The type and degree of drug abuse, the time of last intake and unconscious and the protective reflexes of the airway are taken out
duration of abuse (acute vs. chronic) must be considered to avoid as well as the tone of the GIT sphincters.
deleterious outcomes that affects cardiovascular, pulmonary, • This leaves the airway defenseless for secretions / gastric contents.
central nervous system, renal and hepatic system. • Aspiration of gastric contents, even if minimal, may result in
• Anesthetic management must be planned cautiously. morbidity or mortality due to aspiration pneumonia.

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10. Review of Systems 4. Chest and Lungs

• This part uncovers subjective findings that the patient may have • The examination gives focus on the baseline findings of lung
failed to mention but may point to dysfunction or disease. expansion, chest rise, breath and heart sounds in search for any
9 General (including activity level): conscious, coherent, abnormal findings that may warrant further preoperative testing.
oriented to time, place and person
9 Respiratory: shortness of breath, orthopnea, dyspnea 5. Abdomen
9 Cardiovascular: palpitations, chest heaviness
• In the examination of the abdomen, the anesthesiologist gives
9 Renal: dysuria, hematuria, polyuria
importance to any findings that may point to an increase in
9 GIT: hematemesis, melena, hematochezia
intraabdominal pressure.
9 Hematologic: gum bleeding, nose bleeding
• Patients with an increase in IAP presents with numerous
9 Neurologic: numbness, weakness in all extremities
anesthetic implications, depending on the level of pressure.
9 Endocrine: excessive sweating, polydipsia
• These implications may translate to morbidity or even mortality if
9 Psychiatric: visual and auditory hallucinations
not addressed properly.
9 Orthopedic: limitation of movement
• An example is the decrease in lung volumes and capacities in
9 Dermatologic: active skin dermatoses, pruritus
patients with massive ascites.
9 These patients are more prone to desaturation and hypoxia
PREOPERATIVE PHYSICAL
III. upon induction of anesthesia.
EXAMINATION FOR ANESTHESIA
• The second component of the Preoperative Evaluation is the PE. 6. Extremities
• The preoperative PE must be aligned from the history gathered • The anesthesiologist determines the quality of the pulses as a
and must focus on systems affected upon delivery of anesthesia. baseline for comparison intra-operatively, as well as the visibility
• Patient’s baseline findings on vital signs, airway assessment,
and palpability of the veins, at times an additional vascular access
examination of cardiorespiratory systems and other systems play a is needed in the operating room.
crucial role during the perioperative anesthesia period.
• The following are the parts of the PE and its focus in anesthesia.
7. Back / Spine
1. General Survey • Examination includes inspection for gross deformities and active
skin dermatoses that may be a contraindication for regional
• Indicates if patient is in or not in cardiorespiratory distress and anesthesia and palpation of the lumbar spine to assess ease or
must state the degree of severity cardiorespiratory distress. difficulty of lumbar puncture.

2. Vital Signs 8. Neurological Examination

• Height: cm | Weight: kg | BMI: kg/m2 • A focused neurologic exam is performed to find any deficits that
• Blood pressure in mmHg may affect general and regional anesthesia techniques.
• Heart rate in beats per minute • More importantly, the neurologic exam is performed to obtain a
• Respiratory in cycle per minute baseline, to determine any improvement or deterioration of
• Pain score (level of pain) using 1-10 scale function in patients who will undergo neurosurgical procedures.
9 0 – no pain; 10 – severe pain

9. Preoperative Tests
3. Head and Neck
• Preoperative Tests are included for the purpose of identification
• The examination should focus on airway evaluation and the and verification of a disease or disorder that may affect during
predictors of difficult ventilation or difficult intubation. perioperative anesthetic care and formulation of anesthetic plans
• The most common classification used for airway evaluation is the
and alternatives for the proposed procedure.
Mallampati Scoring • This part of the preanesthetic evaluation is often used to determine
fitness for surgery and anesthesia and to identify patients at high
risk of postoperative complications.

9.1 Selection and Timing of Preoperative Tests

• Surgeons and anesthesiologists and even patients request a full
panel of laboratory testing prior to surgery.
• A lot of which may not give any important information that may
cause or prevent perioperative morbidity or mortality.
📌 Scan the QR Code: Mallampati Classification • The ASA Task Force updated report (March 2012) on the
preanesthesia evaluation recommends that preoperative tests
should not be ordered routinely.
• Routine test: defined as a test required in the absence of a
specific clinical indication.
• Indications for routine testing must be based from:
9 Medical records 9 Physical examination
9 Patient interview 9 Type of surgical invasiveness
• Indicated test: defined as a test that is requested for a specific
clinical purpose, for example, patients who are taking warfarin,
warrants a detailed coagulation studies

9.2 Hemoglobin / Hematocrit

Soft palate, uvula, Soft palate, uvula, Only base of uvula Uvula not visualized • A routine preanesthesia hemoglobin or hematocrit is not indicated.
fauces and tonsillar and fauces seen – visualized No structures seen • Indications for hemoglobin and hematocrit includes:
pillars are visualized tonsillar pillars not only soft tissues 9 Surgical invasiveness 9 History of anemia
visualized 9 Patients with liver disease 9 Bleeding / hematologic disorders
Figure 38-3. Mallampati classification: class I, soft palate, fauces, entire 9 Extremes of age
uvula, pillars; class II, soft palate, fauces, portion of uvula; class III, soft
palate, base of uvula; class IV, hard palate only.

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9.3 Electrocardiogram ASA Classes and Examples

• ECG is indicated for patients with: Class 1 Healthy, non-smoking, no or minimal alcohol use
9 Cardiocirculatory disease Class 2 Mild diseases only without substantive functional
9 Respiratory disease limitations. Examples include but not limited to:
9 Type of surgical invasiveness • Current smoker
• ECG abnormalities are common in older patients with multiple • Social alcohol drinker
cardiac risk factors as well. • Pregnancy
• Obesity (30 < BMI < 40)
9.4 Chest Radiographs • Well controlled DM / HTN
• Mild lung disease
• Preanesthesia chest radiographs are considered in patients with:
9 History of smoking
Class 3 Substantive functional limitation; ≥1 moderate to severe
9 Recent upper respiratory infection
diseases. This includes (but not limited to):
• Poorly controlled DM / HTN
9 Chronic obstructive pulmonary disease (COPD)
9 Cardiac disease
• COPD
• Morbid obesity (BMI >40)
• Active hepatitis
9.5 Pulmonary Diagnostic Examinations
• Alcohol dependence or abuse
• Pulmonary function tests, arterial blood gas monitoring • Implanted pacemaker
• May guide anesthesiologists in planning and choosing the ideal • Moderate reduction of ejection fraction
anesthetic for the patient. • ESRD undergoing regular hemodialysis
• Clinical characteristics to consider include:
• Premature infant PCA <60 weeks
9 Surgical invasiveness
• History (>3 months) of MI, CVA or CAD / stents
9 Interval from last evaluation
Class 4 Examples include (but not limited to):
9 Resolved or symptomatic asthma or COPD
• Recent (<3 months) MI, CVA, TIA or CAD/ stents
9 Scoliosis with restrictive function
• Ongoing cardiac ischemia/ severe valve dysfunction
9 Patients with critical illness
• Severe reduction of ejection fraction
• Sepsis, DIC, ARD or ESRD not undergoing regular
10. Cardio-Pulmonary Evaluation hemodialysis
• Not a “Clearance” Class 5 Examples include (but not limited to):
• This is a referral by the surgeon, anesthesiologist or at times even • Ruptured abdominal aneurysm / thoracic aneurysm
the patient himself to an internist, for the evaluation of the cardiac • Massive trauma
and pulmonary status and the risk assessment of the patient for • Intracranial bleed with mass effect
the planned procedure. • Ischemic bowel in the face of significant cardiac
• At present, there are a lot of cardio-pulmonary evaluation indices pathology or multiple organ system dysfunction
and classifications being used in practice. Some examples are: Class 6 A declared brain-dead patient for organ donor purposes
9 Goldman Multifactorial Risk Index
9 Eagle’s Cardiac Risk Index
9 AHA Cardiac Risk Classification
IV. THE ANESTHETIC PLAN
9 AHA Perioperative Risk Assessment
• In the formulation of an anesthetic plan, the anesthesiologist
• When applicable other organ systems may be evaluated too, such
should take into consideration of all of the following factors:
9 The age of patient
as an endocrinology clearance for patients with diabetes, thyroid
9 Physical status of patient
or adrenal diseases.
9 The type of surgery or procedure to be performed
• The American Society of Anesthesiologists (ASA) has its own
9 The skill and requirement of the surgeon
physical status evaluation tool and this is what the Philippine
9 The skill and preference of the anesthesiologist
Society of Anesthesiologists (PSA) follow.
9 The patient’s preference and wishes

ASA Physical Status Classification (Updated 2014) • After considering all of these factors, the anesthesiologist decides
which technique is safest for the patient and most effective for the
Class 1 A normal healthy patient
procedure.
Class 2 A patient with mild systemic disease and no functional
• Good communication is very important between the surgeon and
limitations
anesthesiologist at this point.
Class 3 A patient with moderate to severe systemic disease that
• Multidisciplinary preoperative conferences (with the surgeon,
results in some function limitation
anesthesiologist, other attending physicians and the patient and
Class 4 A patient with severe systemic disease that is a his family) are held when necessary to discuss important aspects
constant threat to life and functionally incapacitating of the procedure which includes the possible complications, risks
Class 5 A moribund patient who is not expected to survive 24 and outcomes.
hours with or without surgery • This is held to address concerns, to manage expectations, to
Class 6 A brain-dead patient whose organs are being harvested answer questions that may be present and to ensure that every
“E” If the procedure is an emergency, the physical status is member of the team including the patient is on-board.
followed by an “E”
📌 See next page for the Algorithm

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Figure 38-1 Mechanisms by which preoperative evaluation can help

influence and improve perioperative care.

V. CONCLUSION OF PREOPERATIVE
ANESTHETIC VISIT
• The anesthesiologist summarizes pertinent findings from the
history, physical exam and laboratory testing on the Pre-Anesthetic
Evaluation Form to be inserted in patient’s chart / medical record.
• The anesthesiologist orders additional laboratory or diagnostic
tests that are necessary and that will contribute in the perioperative
evaluation and management
• The anesthesiologist writes the pre-anesthesia medication orders.
The goals of giving preoperative medications are the ff:
9 To decrease anxiety
9 To provide analgesia
9 To decrease oral secretions
9 To decrease the risk of aspiration
9 To control sympathetic stimulation (increased HR and BP)
• The anesthesiologist gives instructions to the patient.
9 Instructions on placing the patient on NPO / fasting status
9 Instructions on which maintenance medications should be
continued or discontinued (anti-hypertensives, oral
hypoglycemic, etc.)
9 Instructions on giving premedications. The patient is not
allowed to ambulate after giving premedications due to the
sedative and autonomic effects of the drugs.
9 Other instructions given for special procedures.
• The anesthesiologist and the patient ratify the Informed Consent.
Consent stated that the anesthesiologist explained the
management plan, including the possible risks and outcomes, and
the patient has understood and accepted the management.

📌 No proofreading. Use at your own risk.

No samplex attached. Good luck!

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