KULIAH COAS

The PreOPERATIVE Evaluation

Department of Anesthesiology, Pain Management and Intensive Care
Dr.Wahidin Sudirohusodo Hospital Faculty of Medicine 
University of Hasanuddin
Makassar ­ Indonesia
 INTRODUCTION

 Relevant information is obtained by a chart review

followed by the patient interview.
 Knowledge of the patient's history when beginning
the interview is reassuring to the anxious patient.
 Although patient age and American Society of
Anesthesiologists (ASA) Physical Status
Classification
ANESTHETIC HISTORY

Old anesthesia records should be reviewed for

the following information:
a. Response to sedative/analgesic premedications and
anesthetic agents.
b. Ease of mask ventilation, direct laryngoscopy, and the size
and type of laryngoscope blade and endotracheal tube
used.
c. Vascular access and invasive monitoring used and
difficulties encountered.
d. Perianesthetic complications
FAMILY HISTORY

A history of adverse anesthetic outcomes in

family members should be evaluated. This
history is perhaps best obtained with open-
ended questions, such as “Has anyone in your
family experienced unusual or serious reactions
to anesthesia?” Patients should be specifically
asked about a family history of malignant
hyperthermia.
SOCIAL HISTORY
1.Smoking.
Eliminating cigarette use for 2 to 4 weeks before elective
surgery may reduce airway hyperreactivity and perioperative
pulmonary complications.
2. Drugs and alcohol.
Acute alcohol intoxication will decrease anesthetic requirements
and predispose to hypothermia and hypoglycemia. The routine
use of opioids and benzodiazepines may significantly increase
the doses needed to induce and maintain anesthesia or to
provide adequate postoperative analgesia.
REVIEW OF SYSTEMS
1. A recent history of an upper respiratory
infection.
2. Asthma
3. Preexisting coronary artery disease (CAD),
which may predispose the patient to myocardial
ischemia, ventricular dysfunction, or myocardial
infarction with the stress of surgery and
anesthesia.
4.Diabetes
5. Untreated hypertension, which is frequently associated
with blood pressure lability during anesthesia.

6. Hiatal hernia with esophageal reflux symptoms, which

increases the risk of pulmonary aspiration and may
alter the anesthetic plan.

7. Likelihood of pregnancy and timing of last menses in

women of childbearing age
PHYSICAL EXAMINATION

1.Vital signs
a. Height and weight
b. Blood pressure
c. Resting pulse is noted for rhythm, perfusion
(fullness), and rate.
d. Respirations are observed for rate, depth, and
pattern while at rest.
2. Head and neck
Specific findings that may indicate a difficult airway
include:
a. Inability to open the mouth.
b. Poor cervical spine mobility.
c. Receding chin (micrognathia).
d. Large tongue (macroglossia).
e. Prominent incisors.
f. Short muscular neck.
g. Morbid obesity.
THE MALLAMPATI CLASSIFICATION

I II III IV
3. Precordium.
Auscultation of the heart may reveal murmurs, gallop rhythms, or a
pericardial rub.

4. Lungs.
Auscultation may reveal wheezing, rhonchi, or rales, which should be
correlated with observation of the ease of breathing and use of accessory
muscles of respiration.

5. Abdomen.
Any evidence of distention, masses, or ascites should be noted, because these
might predispose to regurgitation or compromise ventilation.
6. Extremities.
Muscle wasting and weakness should be
documented, as well as general distal perfusion,
clubbing, cyanosis, and cutaneous infection
7. Back.
Note any deformity, bruising, or infection.
8. Neurologic examination.
Document mental status, cranial nerve function,
cognition, and peripheral sensorimotor function.
LABORATORY STUDIESROUTINE
A. Recent hematocrit/hemoglobin level.
A hematocrit screen is recommended for neonates up
to 6 months of age, women over 50 years of age, and
men over 65 years of age.
B. Serum chemistry studies are ordered only when specifically indicated by
the history and physical examination.
 Hypokalemia.

Mild hypokalemia (2.8 to 3.5 mEq/L) should not preclude elective

surgery. Efforts to rapidly correct hypokalemia with IV replacement
therapy may lead to arrhythmias and cardiac arrest.
 Platelet function.

A history of easy bruising, excessive bleeding from gums or minor cuts,

and family history.
 Coagulation studies are ordered only when clinically indicated (e.g.,
history of a bleeding diathesis, anticoagulant use, or serious systemic
illness)
C. An electrocardiogram (ECG) is advisable for men over 40 years
of age and women over 50 years of age. Although the resting ECG
is not a sensitive test for occult myocardial ischemia, an
abnormal ECG mandates correlation with history, physical
examination, and prior ECGs and may require further workup
and consultation with a cardiologist before surgery.

D. Chest radiography should be performed only when clinically

indicated (e.g., heavy smokers, the elderly, and patients with
major organ system disease including malignancy and
symptomatic heart disease).
 Walter Reed Ambulatory Processing Center Current Guidelines
Pt Status Hgb Pt/PTT PLT T/S K+ Bun/Cr Gluc CXR EKG
Age < 6 mo X
Age < 40 yr Female M>40
Age 40-60 yr Female F>50
> 60 yrs X X X X X
Procedure with
Blood loss X X X
Associated
Conditions
Cardiovasc Dz X X X X
Pulmo Dz X X X
Smoker > 20 X X X
Liver Dz X
Renal Dz X X X
Diabetes X X X X
Cancer X X
Pt Status Hgb Pt/PTT PLT T/S K+ Bun/Cr Gluc CXR EKG

Anticoagulant X X
Digoxin X X X X
Diuretic X X
Corticosteroids X X

Urinalysis- symptoms of UTI or procedure involving use of prosthetic material

ASA CLASSIFICATION
 Introduced in 1941 to provide a basis for
comparison of statistical data
 Revised in 1961
I Healthy
II Mild systemic disease, no functional limitation
III Severe systemic disease-definite functional limitation
IV Severe systemic disease that is constant threat to life
V Moribund patient for heroic procedure
VI Organ donation
E Emergent Procedure
 WHAT DOES THE ASA CLASSIFICATION MISS ?
1. Hx of Airway Problems (i.e. sleep apnea) and examination of the airway
2. Risk & complexity of planned surgical procedure
• Low risk = minimal physiologic stress; rarely requires blood transfusion,
invasive monitoring, or ICU care.
• Medium risk - moderate physiologic stress, e.g., laparoscopic
cholecystectomy, abdominal hysterectomy.
• High risk = almost always requires blood administration and/or large
amounts of fluids, invasive monitoring, and postoperative management in
an ICU setting.
3. Potential for adverse reaction due to anesthesia specific disorders
1. Personal / Family history of requiring intubation several hours after minor
surgery
2. MH
3. Burns / Deenervation injuries
GUIDELINES FOR NPO STATUS

Generally, adults should not eat solids after midnight

of the day before surgery but may have clear fluids
up to 2 hours before their procedure.
Infants or children may have milk, formula, breast
milk, or solid food up to 6 hours before surgery and
clear liquids up to 2 hours before surgery.
More restrictive instructions may be necessary for
some patients, such as those with active reflux or
those undergoing gastrointestinal tract operations.
PREMEDICATION
A. The goals of administering sedatives and analgesics before surgery are to allay
the patient's anxiety; prevent pain during vascular cannulation, regional
anesthesia procedures, or positioning; and facilitate a smooth induction of
anesthesia. It has been shown that the requirement for these drugs is reduced
after a thorough preoperative visit by an anesthesiologist.

1. In elderly, debilitated, or acutely intoxicated patients and in those with upper

airway obstruction or trauma, central apnea, neurologic deterioration, or
severe pulmonary or valvular heart disease, doses of sedatives and analgesics
should be reduced or withheld.

2. Patients addicted to opioids and barbiturates should be premedicated

sufficiently to prevent withdrawal during or shortly after surgery.
PREMEDICATION

A. Sedatives
1. Benzodiazepines
a. Diazepam (Valium) 5 to 10 mg orally (PO)
b. Lorazepam (Ativan) (1 to 2 mg PO)
c. Midazolam 1 to 3 mg IV or IM
2. Barbiturates
3. Droperidol 0.03 to 0.14 mg/kg IM
or IV
B. Opioids are most frequently given in the
preoperative setting to relieve pain (e.g., patient
with a painful hip fracture) and occasionally when
the placement of extensive invasive monitoring
devices is planned. Morphine is the primary opioid
used, because it has both analgesic and sedative
properties. Usual adult doses are 5 to 10 mg IM, 60
to 90 minutes before coming to the operating
room.
C. Anticholinergics are seldom used preoperatively.
Occasionally useful agents include the following
1. Glycopyrrolate (0.2 to 0.4 mg IV for adults and 10 to 20 µg/kg for
pediatric patients) or atropine (0.4 to 0.6 mg IV for adults and
0.02 mg/kg for pediatric patients) is given IV during ketamine
induction and during oral/dental surgery as an antisialagogue.

2. Scopolamine may be given in combination with morphine IM

before cardiac surgery to provide additional amnesia and
sedation. The adult dose is 0.3 to 0.4 mg IM.
TERIMA KASIH