PREOPERATIVE
ASSESSMENT
NURUL NAJIEHAH NAJWA BINTI MUSA
What is preoperative assessment?
Process of clinical assessment prior to commencement of
anaesthetic care for surgical/non-surgical procedures
1. Assessment (History and physical examination)
2. Estimate risk
3. Review/ request appropriate basic or advanced investigations
4. Planning risk reduction strategies
5. Planning post operative care
6. Documentation
7. Providing information to patient & caretaker
Why is it important?
• Anticipating potential difficulties and formulates a suitable perioperative plan to
avoid or minimize crisis hence improves patient’s safety
• Ensuring that the patient is medically fit and stable for the surgery and
anaesthesia via preoperative optimization
• Deciding the appropriate equipment, numbers and seniority of staff who will be
needed during administration of anaesthesia related to individual co morbidities
and types of surgery
• Providing the opportunity for patients to ask questios and clarify matters
concerning anaesthestic care
• Obtained consent
• Improving patient outcomes postoperatively
Assessment –history
• A focused history
• Relevance to anaesthesia
• Taken from patient/caretaker/previous medical record
• Presenting condition, urgency of planned surgery
• Co-morbidities and its current status
• Risk assessment
• Previous anaesthetic & surgical history
• Difficult intubation, post-operative ICU admission, prolonged ICU stay
• Allergy history
• Smoking habits
• Alcohol consumption
• Hereditary conditions relevant to anaesthesia
• ex: malignant hyperthermia, porphyria
• Presence of recent/ active URTI
• Time of last oral intake
Physical examination
Physical examination may detect abnormalities that not apparent from the history
• General physical examination (including vital signs)
• Airway assessment-to anticipate difficult airway
• Patient’s dentition
• Poor fit of anaesthesia mask should be expected in edentulous patients/significant facial
abnormalities
• Peripheries-for IV access
• RA-bony landmarks/ area suitability
• Documents any pre-existing neurological deficit if present
Airway assessment
• Mallampati test
• Inter incisor gap
• Mandibular protrusion test
• Thyromentaldistance (TMD) or Patil’s test
• Atlanto-occipital (AO) joint extension
Mallampati test
Inter-incisor gap and temporomandibular joint
• Measure distance between upper & lower incisors teeth
• Normal value: 4-6 cm (3FB)
• < 3 FB: reduce mobility of TMJ to open the mouth/difficult
laryngoscopy and insertion of supraglottic airway
• Causes: ankylosis, fibrosis, tumour etc.
Mandibular protrusion test
Thyromental distance (tmd / patil’s test) & Sternomental distance (savva test)
• Patient need to fully extend the neck
• TMD: <6 cm (3FB) predicts difficult laryngoscope
• SMD: <12 cm predicts difficult laryngoscope
Atlanto-occipital (ao) joint extension
• Visual estimation of angle transversed by
occlusal upper teeth
• Predicts the feasibility of patient to
perform ‘sniffing/Magill position’
• To align 3 anatomical axes-oral, pharyngeal,
laryngeal axes during laryngoscopy
• Grade III, IV : difficult laryngoscopy
Estimate risk
• Using risk assessment tools:
• American Society of Anaesthesiologist (ASA) physical status classification
system
• METs scoring system
ASA PHYSICAL STATUS CLASSIFICATION SYSTEM
• Relates to patient’s general health upon presentation for a surgical
procedure
• Advantages:
• time honored, simple, reproducible, strongly associated with perioperative
risk
• Limitations:
• No moderate systemic disease between ASA II and III which is neither mild or
severe
• No clear class for patient with >2 systemic disease of different degree of
severity
METs METs Activity Classification
METS SCORING
1-4 Eating and talking, bathing, ironing, sweeping floor, stair climbing (slow Poor
pace), sitting
4-7 Moving furniture, bicycle (leisure), digging, recreational swimming Moderate
7-10 Stair climbing (fast pace), jigging, race walking, aerobics Good
>10 Bicycling (racing), squash, martial arts (karate, boxing), competitive Excellent
football, heavy labour
• Quantify o2 consumption by the body during physical activity
• One (1) METs is assumed to be 3.5ml/kg/minute of O2 consumed by
40 years old , 70 kg man at resting state
• METs <4: poor outcome following major surgery
• Inaccuracies-assessment depends on subjective reporting of exercise
capacity by patient
Review/ request appropriate basic or advanced investigations
• Basic investigation
• FBC, RP, Coagulation profile, ECG, CXR
• Advanced investigation related to pt
• ECHO, pulmonary function test
• Investigations indicated in:
• Identifying or verifying a disease/disorder
• Evaluating the extent of current disease/disorder
• Deciding which anaesthetic technique or alternatives suitable for patient
Risk reduction strategy
• proper consultation/ referral to another healthcare discipline to optimize pre-existing
Optimizing patient’s medical condition
medical condition
• Depends on:
Planning & discussing modes of anaesthesia and • related surgical procedure, patient’s comorbid status, advantage & disadvantage of
analgesia
anaesthetic technique, patient’s wish
• Primary aim: relief anxiety, alleviate pain, improves cooperation
Preoperative drugs (premedication) • Secondary aim: reduction of induction and inhalational agent
Justifying patient’s own regular medication • Continued/adjusted/withhold medications that could interact with anaesthetic drugs
• Prevent aspiration (during GA)
• Recommended min. fasting period:
Fasting guidelines • 6 hours: solid food, infant formula, milk
• 4 hours: breast milk
Premedication (7 a’s)
• Anxiolysis
• Alleviate anxiety
• Eg: Benzodiazepine
• Amnesia
• Beneficial for patient undergoing invasive procedure prior to anaesthesia
• Eg: Benzodiazepine
• Analgesia
• Eg: paeds-EMLA prior to set venepuncture
• Anti-emesis
• Patient with risk of PONV (pregnant, hx of motion sickness, intra-
operative opiods, volatile anaesthesia)
• Ex: Metochlopromide
• Antacid
• To alter gastric secretion and reduce its volumeprophylaxis against
gastric acid aspiration
• Indication for patient: obese, obstetric, hiatus hernia, reflux oesophagitis
• Eg: H2 receptor antagonist, PPI, non-particulate antacid
• Antisialogogue
• Anti-cholinergic : reduce salivation
• Facilitates in AFOI
• Additional
• Eg: antibiotics, steroids, nebulizer
Planning post operative care
• Depends on anaesthesia method chosen
• Eg: APS review is required for patient receiving epidural infusion from CSE
method
• Decision of postoperative care in general ward, HDU or ICU are
determined by premorbid status and the course of any adverse events
perioperatively
Documentation
• Adequate documentation provides guidance to those who may
encounter the patient in the future.
• It permits others to assess the quality of the care that was given and
• It provides risk adjustment of outcomes.
• Adequate and well-organized documentation supports a potential
defense case if medical malpractice is filed
• Pre-operative assessment notes
• Example: Medical history, anesthetic history, current medications, physical
examination, ASA physical status class, laboratory results, interpretation of
imaging, electrocardiograms, and recommendations of any consultants.
• briefly describe the anesthetic plan and include informed consent from the
patient (or guardian).
• Intraoperative anaesthesia record
• Functions : Intraoperative monitoring, a reference for future anaesthetics for
that patient, source of data for quality assurance.
• Postoperative notes
• Document patient’s recovery from anesthesia, any apparent anaesthesia
related complications, the immediate postoperative condition of the patient
• Recovery from anaesthesia should be assessed at least once within 48 h in all
patients.
REFERENCES
• Morgan & Mikhail’s Clinical Anaesthesiology
• CPG 2014
• Basic Anaesthesia Handbook
