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Preanesthetic

assessment
9 Juli 2016
Preanesthetic assessment (also called Preanesthesia
evaluation, Pre-anesthesia checkup (PAC)

preanesthesia evaluation is defined as the process of clinical


assessment that precedes the delivery of anesthesia care for
surgery and for non- surgical procedures.

medical check-up and laboratory investigations done by the


anesthesiologist before an operation, to assess the patient's
physical condition and any other medical problems or
diseases the patient might be suffering from
- The goal of the assessment is to identify factors that
significantly increase the risk of complications, and modify
the procedure appropriately.

- The aim is to identify the appropriate anesthetic techniques


to be used, to ensure the safety of perioperative care,
optimal resource use, improved outcomes, and patient
satisfaction, while considering the individual and person
related risk factors and circumstances.
- Content of the preanesthetic evaluation includes but is not to
(1) readily accessible medical records, (2) patient interview,
(3) a directed preanesthesia examination, (4) preoperative
tests when indicated, and (5) other consultations when
appropriate.

- At a minimum, a directed preanesthetic physical


examination should include an assessment of the airway,
lungs, and heart.
General recommendations have been published in the USA
and in India.

A mnemonic has been suggested for pre-anesthetic


assessment, to ensure that all aspects are covered. It runs
alphabetically:
A - Affirmative history; Airway
B - Blood hemoglobin, blood loss estimation, and blood
availability; Breathing
C - Clinical examination; Co-morbidities
D - Drugs being used by the patient; Details of previous
anesthesia and surgeries
E - Evaluate investigations; End point to take up the case for
surgery
F - Fluid status; Fasting
G - Give physical status; Get consent
J Anaesthesiol Clin Pharmacol. 2013 Oct-Dec; 29(4): 560–561.
doi: 10.4103/0970-9185.119127
PMCID: PMC3819859
V. R. Hemanth Kumar, Ashish Saraogi, S Parthasarathy, and M
Ravishankar
Because the incidence of perioperative cardiovascular
events varies according to:
- patient risk profile
- risk of the proposed surgery
- patient's functional capacity
- all of these elements should be parts of the preoperative
history.

The clinician should inquire about prior:


- Myocardial infarction(MI)
- congestive heart failure
- valvular disease
- angina
- arrhythmia.
Traditional risk factors, such as hypertension, dyslipidemia,
tobacco use, and diabetes, are essential elements, as well as
comorbid conditions that might limit functional capacity such
as peripheral vascular disease, chronic obstructive pulmonary
disease, cerebrovascular disease, and renal insufficiency.

Current symptoms such as chest pain at rest or on exertion,


shortness of breath, claudication, syncope or presyncope, or
anginal equivalent symptoms should be noted.
Reduction in Complications

- Well-timed preoperative smoking cessation can reduce


postoperative complications, particularly wound and
pulmonary.
- Several randomized trials have achieved 20%-30%
absolute risk reductions in complications with interventions
started 4-8 weeks preoperatively [Møller Lancet
12;359(9301):114-7, 2002; Lindström Ann Surg 248(5):
739-45, 2008].
- A Cochrane review [Thomsen Cochrane Database Syst Rev
27;3:CD002294, 2014]: preoperative interventions were
effective in reducing postoperative complications
Timing of Cessation

- The length of time necessary to benefit previous smokers is not exactly


clear.
- Twelve to 24 hours is enough to decrease carboxyhemoglobin levels and
shift the dissociation curve rightward (increasing oxygen availability to
tissues).
- One to 2 weeks may be enough to reduce sputum volume [Moore Clin
Chest Med 21: 139, 2000].
- A systematic review of 25 studies on the optimal timing of smoking
cessation [Wong Can J Anaesth 59:268-279, 2012] concluded that at least
4 weeks of abstinence from smoking reduced respiratory complications,
and abstinence of at least 3 to 4 weeks reduced wound healing
complications.
- Short-term (<4 weeks) smoking cessation did not appear to increase or
reduce the risk of postoperative respiratory complications.
- Vital signs can detect hypertension or hypotension,
tachycardia or bradycardia, significant arrhythmias, or
hypoxia if pulse oximetry is used.
- Jugular venous distention, the presence of a S3 gallop, or
rales suggest decompensated heart failure.
- Cardiac murmurs should be noted, especially if aortic
stenosis is suspected.
- Carotid, femoral, or abdominal bruits suggest peripheral
vascular or cerebrovascular disease.

http://www.clevelandclinicmeded.com/medicalpubs/
diseasemanagement/preventive-medicine/perioperative-
evaluation/
Patients limited in their activity from noncardiac causes, such
as severe osteoarthritis or general debility, are categorized
as having poor functional capacity, because one cannot
discern if significant cardiac conditions exist without the
benefit of a functional study (noninvasive testing).
- Postoperative pulmonary complications (PPCs) are equally
prevalent compared with cardiac complications and
contribute similarly to morbidity, mortality, and length of
postoperative hospital stay.
- Patient factors increasing the risk for PPCs include chronic
obstructive pulmonary disease, age older than 60 years,
American Society of Anesthesiologists (ASA) class II or
greater, functional dependence, and congestive heart
failure.
- Obesity and mild to moderate asthma have not been
consistently shown to predict PPCs.
- A low serum albumin level (<35 g/dL) has been found to be
a powerful predictor of PPCs, likely as a reflection of
impaired general health or immune compromise.
Surgical factors increasing PPC risk include thoracic or
abdominal surgical site (which can lead to splinting due to
pain and impaired diaphragmatic excursion); neurosurgery;
head and neck procedures; vascular procedures, especially
abdominal aortic aneurysm repair; any emergent procedures;
use of general anesthesia; and prolonged (>3 hr) procedures.
Routine pulmonary function testing and chest radiography:
- are not indicated preoperatively because they do not predict
PPCs
- the patient is symptomatic, has unexplained dyspnea, or is
undergoing lung volume reduction surgery or other
intrathoracic procedures.

Interventions that successfully reduce PPCs in high-risk


patients include incentive spirometry or deep-breathing
e x e rc i s e s a n d s e l e c t i v e u s e o f n a s o g a s t r i c t u b e
decompression.
Cardiac Risk Index in Noncardiac Surgery (Goldman, et. al.)
Select Criteria:
History
Age > 70 years (5 points)
Myocardial infarction within 6 months (10 points)
Cardiac Exam
Signs of CHF: ventricular gallop or JVD (11 points)
Significant aortic stenosis (3 points)
Electrocardiogram
Arrhythmia other than sinus or premature atrial contractions (7 points)
5 or more PVC's per minute (7 points)
General Medical Conditions
PO2 < 60; PCO2 > 50; K < 3; HCO3 < 20; BUN > 50; Creat > 3; elevated SGOT; chronic
liver disease; bedridden (3 points)
Operation
Emergency (4 points)
Intraperitoneal, intrathoracic or aortic (3 points)
Results:
Total Criteria Point Count:

Risk Index
0-5 Points: Class I 1% Complications
6-12 Points: Class II 7% Complications
13-25 Points: Class III 14% Complications
26-53 Points: Class IV 78% Complications
Revised Cardiac Risk Index
1. History of ischemic heart disease
2. History of congestive heart failure
3. History of cerebrovascular disease (stroke or transient
ischemic attack)
4. History of diabetes requiring preoperative insulin use
5. Chronic kidney disease (creatinine > 2 mg/dL)
6. Undergoing suprainguinal vascular, intraperitoneal, or
intrathoracic surgery

Risk for cardiac death, nonfatal myocardial infarction, and


nonfatal cardiac arrest:
0 predictors = 0.4%, 1 predictor = 0.9%, 2 predictors = 6.6%,
≥3 predictors = >11%
- Every criteria employed in the RCRI score has independent predictive value and
the accuracy of the study has been validated several times.
- It was developed by Lee in 1999 as derived from the Goldman study on cardiac
risk complications and is now part of the preoperative cardiac risk evaluation
guideline from the American Heart Association and American College of
Cardiology.

Compared to the original study, the revised version appears to be not only easier to
but also more accurate in clinical practice.

Major cardiac events or complications as they are referred to in both risk studies
include:

■ Myocardial infarction;

■ Pulmonary edema;

■ Ventricular fibrillation;

■ Primary cardiac arrest;

■ Complete heart block.


Timing of the preanesthetic evaluation can be guided by
considering combinations of surgical invasiveness and
severity of disease
Three options that practices use for the timing of an initial
preanesthetic evaluation are:
(1) always before the day of surgery
(2) either on or before the day of surgery
(3) only on the day of surgery.
- The majority of consultants and ASA members agree that
for high surgical invasiveness, the initial assessment of
pertinent medical records should be done before the day
of surgery by anesthesia staff.
- For medium surgical invasiveness, the majority of
consultants indicate that the initial assessment of pertinent
medical records should be done before the day of surgery
by anesthesia staff, although the majority of ASA members
indicate that the initial assessment may be done on or
before the day of surgery.
- For low surgical invasiveness, the majority of consultants
and ASA members agree that the initial assessment may
be done on or before the day of surgery.
- The degree of surgical risk contributes to a patient's risk for
cardiac complications.
- In general, procedures that are longer and have greater
potential for blood loss, hemodynamic instability, and
intravascular fluid shifts carry greater risk.
- Procedural risk is often stratified into high (estimated
mortality >5%), intermediate (mortality 1%-5%), and low
(<1%) risk categories.
- An initial record review, patient interview, and physical
examination should be performed before the day of surgery
for patients with high severity of disease.
- For patients with low severity of disease and those
undergoing procedures with high surgical invasiveness, the
interview and physical exam should also be performed
before the day of surgery.
- For patients with low severity of disease undergoing pro-
cedures with medium or low surgical invasiveness, the initial
interview and physical exam may be performed on or
before the day of surgery.
The 12-Lead Electrocardiogram: Recommendations
Class IIa
1.Preoperative resting 12-lead electrocardiogram (ECG) is reasonable
for patients with known coronary heart disease, significant arrhythmia,
peripheral arterial disease, cerebrovascular disease, or other significant
structural heart disease, except for those undergoing low-risk surgery
(Level of Evidence: B)
Class IIb
1.Preoperative resting 12-lead ECG may be considered for
asymptomatic patients without known coronary heart disease, except for
those undergoing low-risk surgery (Level of Evidence: B)
Class III: No Benefit
1.Routine preoperative resting 12-lead ECG is not useful for
asymptomatic patients undergoing low-risk surgical procedures (Level of
Evidence: B)

General consensus suggests that an interval of 1 to 3 months


is adequate for stable patients.
- In the past EKG has been recommended at 40 years of
age for men for all general anesthetics (women at 50).
- recent data suggests this will lead to considerable over-
testing.
- Patients at higher risk of having significantly abnormal
electrocardiograms which would potentially affect
management were those older than 65 yr of age or who
had a history of heart failure, high cholesterol, angina,
myocardial infarction, or severe valvular disease.
Clinical evidence showing appropriate utilization of pre-
operative echocardiography in non-cardiac surgery is scanty.
The resting echocardiography has relatively weak evidence in
predicting post-operative outcomes even in patients with
active cardiac conditions and poor functional status.

In a large population based retrospective cohort review


2,64,823 patients were analyzed and echocardiography
performed in 15.1% of these patients. They found the pre-
operative echocardiography was not associated with
improved outcomes or shorter hospital stay in major non-
cardiac surgery, casting doubts on proper utilization of the
very common pre-operative test.
- Currently, British Society of Echocardiography (BSE) as well as American
Society of Echocardiography (ASE) is establishing guidelines for
Echocardiography in the pre-operative assessment with periodic revision.
- BSE recommends TTE in patients with documented IHD with reduced
functional capacity (<4 metabolic equivalents [METS]), unexplained
shortness of breath in the absence of clinical signs of heart failure, if
electrocardiogram (ECG) and/or chest X-ray are abnormal, murmur in the
presence of cardiac or respiratory symptoms, murmur in an asymptomatic
individual in whom clinical features or other investigation suggest severe
structural heart disease.
- TTE should not be used just to repeat the assessment of previous
echocardiogram with no intervening change in clinical status within 12
months.
- ASE has no clearly defined indication for resting echocardiogram, except
for high-risk vascular procedures in patients with reduced functional
capacity (<4 METS) where only stress echocardiography is recommended.
Year : 2014 | Volume : 30 | Issue : 3 | Page : 313-315
Pre-operative echocardiography: Evidence or experience based utilization in non-cardiac surgery?

Sudhakar Subramani1, Anurag Tewari2


1 Department of Anesthesiology, University of Iowa Hospitals & Clinics, Iowa City, IA 52242, USA,
2 Deparment of Anaesthesiology, Dayanand Medical College, Ludhiana, Punjab, India,
Echocardiography
- Do not routinely offer resting echocardiography before
surgery
- Condiser resting echocardiography if the person has:
a heart murmur and any cardiac symptom (including
breathlessness, pre-syncope, syncope or chest pain) or
signs or symptoms of heart failure

Before ordering the resting echocardiogram, carry out a


resting electrocardiogram (ECG) and discuss the findings
with an anaesthetist.

Routine preoperative tests for elective surgery’, NICE guideline NG45 (April 2016) ©
National Institute for Health and Care Excellence 2016. All rights reserved.
- Functional status is a reliable predictor of perioperative and
long-term cardiac events.
- Patients with reduced functional status preoperatively are at
increased risk of complications.
- Conversely, those with good functional status preoperatively
are at lower risk.
- If a patient has not had a recent exercise test before
noncardiac surgery, functional status can usually be
estimated from activities of daily living.
- Functional capacity is often expressed in terms of metabolic
equivalents (METs), where 1 MET is the resting or basal
oxygen consumption of a 40–year-old, 70-kg man.

1 MET is considered equivalent to the consumption of 3.5 ml


O2·kg−1·min−1 (or 3.5 ml of oxygen per kilogram of body
mass per minute) and is roughly equivalent to the expenditure
of 1 kcal per kilogram of body weight per hour.
Estimated energy requirements for various activities.

Authors/Task Force Members et al. Eur Heart J 2014;35:2383-2431

©The European Society of Cardiology 2014. All rights reserved. For permissions please email:
journals.permissions@oup.com.
The functional status of the patient is a good predictor of both
the cardiac and overall risk of the patient for surgery and
hospitalization.
Thank You