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ANAESTHESIA
PREANAESTHETIC ASSESSMENT
AND MANAGEMENT
“ANAESTHESIA PROVIDER’
PRPD/DHS/2011
PREOPERATIVE ASSESSMENT
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Why preoperative assessment is
important?
How it should be done?
By whom?
What can be expected?
The importance of test selection
based on patient’s needs on
scientific evidence of effectiveness.
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THE AIMS OF PREOPERATIVE
ASSESSMENT
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To reduce the risks associated with
surgery and anaesthesia.
To increase the quality (thus decreasing
the cost) of preoperative care.
To restore the patient to the desired level
of function.
To obtain the patients’ informed consent
for the anaesthetic procedure.
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1. THE PREOPERATIVE VISIT
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The main aim of the preoperative visit is to
assess the patient’s fitness for anaesthesia.
It is performed by an anaesthetist, preferably
the one who is going to administer the
anaesthetic.
All patients would be seen by their anaesthetist
sufficiently ahead of the planned surgery to
allow any problems identified to be treated
without interfering with the smooth running of
the operating list.
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THE PREOPERATIVE VISIT cont….
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The visit allows the most suitable
anaesthetic technique to be determined.
To determine any potential interactions
between concurrent disease and
anaesthesia to be anticipated.
To provide an explaination and
reassurance for the patient.
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THE PREOPERATIVE VISIT cont…
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Where there is co-existing illness,
every opportunity must be taken to
improve the patient’s condition prior
to surgery. This may mean seeking
advice from other specialists to
optimize treatment, although the final
decision will rest with the
anaesthetist.
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SPECIAL ARRANGEMENTS
Three situations:
1. Patients with complex medical or
surgical problems;
- The patient is often admitted several
days prior to surgery.
- The anaesthetist is actively involved
in optimizing their condition prior to
anaesthesia and surgery.
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SPECIAL ARRANGEMENT cont...
2. Surgical emergencies;
- The anaesthetist must be informed as
soon as the decision to operate has
been made and advice sought about
the need for urgent investigations or
treatment.
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SPECIAL ARRANGEMENT cont…
3. Day-case patients;
- Anaesthetic assessment is often
carried out by the surgeon or a
designated clinic nurse according
to protocol, and the patient’s first
contact with the anaesthetist is
on arrival in the day-case unit.
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2. ANAESTHETIC HISTORY AND EXAMINATION
The anaesthetist should take a full history and
examine each patient.
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Previous anaesthetics and operations;
- The patient should be asked if they suffer
from any inherited or ‘family’ diseases or
whether they have experienced any difficulties
with previous anaesthetics e.g., nausea,
vomiting.
- The records of previous anaesthetics must be
checked to rule out or clarify problems such as
difficulties with intubation, drugs administered
or adverse reactions.
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2. ANAESTHETIC HISTORY AND EXAMINATION
cont……
- The approximate date of previous
anaesthetics, particularly if recent, should
be identified to avoid the risk of repeat
exposure to halothane.
- Details of previous surgery may reveal
potential anaesthetic problems, for e.g.,
cardiac or pulmonary surgery.
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2. ANAESTHETIC HISTORY AND EXAMINATION
cont……
 Present and past medical history;
- of all the aspects of the patient’s medical
history, those relating to the cardiovascular and
respiratory systems are the most important .
- the questions and detailed required will vary
depending upon the disease present, its severity,
anticipated anaesthesia and the planned
operation, CVS e.g., angina, VHD, RS e.g., pre
existing lung disease.
- other conditions that are important if identified
in the medical history e.g., indigestion, reflux,
rheumatoid disease, diabetes, neuromuscular
disorder, chronic renal failure, jaundice, epilepsy.
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2. ANAESTHETIC HISTORY AND EXAMINATION
cont……
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Family history;
- any family members had experienced
problems with anaesthesia or whether there are
any known inherited conditions in the family
e.g., prolonged apnoea, an unexplained death,
malignant hyperpyrexia, haemophilia, sickle-cell
disease.
Surgery should be postponed if any of these
conditions are identified and the patient
investigated appropriately.
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2. ANAESTHETIC HISTORY AND EXAMINATION
cont……
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Drug history and allergies;
- All medications, both prescribed and
self administered, should be identified
preoperatively.
- Previous medications should be
identified, especially if there was any
adverse reaction.
- Allergies to drugs, topical preparations
(e.g. iodine), adhesive dressings and
foodstuffs should be noted.
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2. ANAESTHETIC HISTORY AND EXAMINATION
cont……
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Social history;
1. Smoking
Ascertain how long the patient has been
smoking and what their consumptions of
cigarettes or grams of tobacco per day.
The adverse effects include: a reduced oxygen
carriage due to raised carboxyhaemoglobin
levels; tachycardia, hypertension and coronary
artery narrowing caused by nicotine stimulating
the sympathetic nervous system.
Smokers have a significant increase in
postoperative chest infections, chronic lung
disease and carcinoma.
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2. ANAESTHETIC HISTORY AND EXAMINATION
cont……
Stopping smoking for:
- eight weeks improves the airways
- two weeks reduces their irritability
- as little as 24 hours prior to anaesthesia
decreases carboxyhaemoglobin levels.
2. Alcohol
This is best measured as units consumed per
week. Excessive consumption (>50 units/week)
causes induction of liver enzymes and tolerance
to anaesthetic drugs.
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2. ANAESTHETIC HISTORY AND EXAMINATION
cont……
3. Drugs
Ask specifically about the use of drugs for
recreational purposes including; type,
frequency and route of administration.
4. Pregnancy
The date of the last menstrual period should be
noted in all women of child-bearing age.
Anaesthesia increases the risk of inducing a
spontaneous abortion in early pregnancy.
There is an increased risk of regurgitation and
aspiration in late pregnancy. Elective surgery is
best postponed until after delivery.
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2. ANAESTHETIC HISTORY AND EXAMINATION
cont……
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The examination
As with the history that is taken, the
examination concentrates on the
cardiovascular and respiratory systems.
Attention must also be paid to the airway, in
order to try and identify those patients in
whom there may be potential problems.
The remaining systems are examined if
problems relevant to anaesthesia are
identified.
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2. ANAESTHETIC HISTORY AND EXAMINATION
cont……
1. Cardiovascular system
Determine whether there are any
arrhythmias, for e.g., atrial fibrillation, and
look for signs of heart failure.
The patient’s blood pressure should be taken
and compared with that recorded by the
nursing staff.
The peripheral veins should be inspected to
identify any potential problems with
intravenous access.
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2. ANAESTHETIC HISTORY AND EXAMINATION
cont……
2. Respiratory system
Look for cyanosis, the pattern of ventilation and
count the respiratory rate. Dyspnoea may be
present at rest. Wheeziness, signs of collapse,
consolidation and effusion should be identified.
3. Nervous system
Chronic disease of the peripheral and central
nervous systems should be identified and any
evidence of motor or sensory impairment
recorded e.g., myotonica, multiple sclerosis.
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2. ANAESTHETIC HISTORY AND EXAMINATION
cont……
4. Musculoskeletal
Patients with connective tissue disorders should
have any restriction of movement and
deformities noted.
Patients suffering from chronic rheumatoid
disease frequently have a reduced muscle
mass, peripheral neuropathies and pulmonary
involvement.
Particular attention should be paid to the
patient’s cervical spine and temporomandibular
joints.
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2. ANAESTHETIC HISTORY AND EXAMINATION
cont……
5. The airway
At the preoperative visit, all patients
must have an assessment made of their
airway, irrespective of the technique
planned for airway maintenance during
anaesthesia.
The main objective is to try and predict
those patients in whom there may be
difficulty with intubation.
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2. ANAESTHETIC HISTORY AND EXAMINATION
cont……
Assessment is often made in three stages;
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Observation of the patient’s anatomy – any
limitation of mouth opening, a receding
mandible, health of teeth etc..
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Simple bedside tests – Wilson score, Mallampati
criteria, Thyromental distance.
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X-rays; measurements made on the lateral
x-ray of the head and neck.
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MALLAMPATI ASSESSMENT
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LARYNX (VOICE BOX)
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Thyromental Distance
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3. SPECIAL INVESTIGATIONS
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Baseline investigations Hb, ECG, blood
sugar, creatinine.
Additional investigations – dictated by
the presence of other disease processes
such as U&E, LFT, BS, ECG, Chest X-ray,
PFTs, Coagulation screen etc..
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4. MEDICAL REFERRAL
Assist in improving the preoperative fitness of
patients:
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Any patient discovered or known to have coexisting medical (or surgical) problems must
have their condition optimized prior to
anaesthesia to reduce the risks of unnecessary
complications.
Postponing surgery and requesting the
involvement of other specialists for advice
about treatment in order that the patient is in
the best possible physical condition.
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4. MEDICAL REFERRAL cont…
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The role of Physiotherapist in improving
patients with respiratory problems,
either as a result of pulmonary
pathology, e.g., Chronic obstructive lung
disease or secondary to neuromuscular
or musculoskeletal disorders.
Other wide spectrum conditions: CVD,
Respiratory D, Endocrine D, Renal D,
Haematological Disorders.
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5. RISK ASSESSMENT
The anaesthetist try to assess the
risks of anaesthesia (and surgery).
These range from minor morbidity
e.g., cut lip or a sore throat after
difficult intubation to the ultimate risk
of death of the patient.
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6. INFORMING THE PATIENT
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The anaesthetist will explain the events the
patients will experience in the perioperative
period.
The patient is instructed to fast prior to surgery.
Clear instructions regarding arrangements for
taking their normal medications and whether
they can have small amount of water to take
tablets.
The route of administration and approximate
timing if a premedication is prescribed and
discuss the likely effects.
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6. INFORMING THE PATIENT cont…
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The choice of anaesthesia for a given
surgical procedure is made by the
patient, the anaesthesia provider, and
the surgeon.
A variety of factors influence this choice
including patient’s physiologic status,
presence and severity of coexisting
diseases, type and duration of the
surgical procedure, patient’s position
during surgery etc…
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7. PREMEDICATION
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Premedication originally referred to those
drugs administered to facilitate the
induction and maintenance of anaesthesia
e.g., morphine and atropine.
Consequently, a wide variety of drugs are
used, with a variety of aims. The 6As of
premedication:
Anxiolysis, Amnesia, Anti-emetic, Antacid,
Anti-autonomic and Analgesic
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IMMEDIATE PREANAESTHETIC
ASSESSMMENT BEFORE SURGERY
The anaesthesia provider will;
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Reviews the patient’s chart, laboratory
data and diagnostic studies such as the
ECG and chest x-ray examination.
Confirms that the appropriate consent
forms (surgery, anaesthesia, use of
blood products) have been signed.
Identifies the patient.
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IMMEDIATE PREANAESTHETIC
ASSESSMMENT BEFORE SURGERY cont..
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Verifies the surgical procedure.
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Review the choice of anaesthesia.
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Examines the patient.
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Gives preoperative medications if
appropriate.
The End
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