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PRE-OP

ASSESSMENT
DR. AYESHA EHSAN
House Surgeon S-II
Definition
• The pre-operative period runs from the time the patient is admitted
to the hospital till the time when the surgery begins
• The pre-operative assessment is an opportunity to identify co-
morbidities that may lead to patient complications during the
anaesthetic, surgical, or post-operative period. Patients scheduled for
elective procedures will generally attend a pre-operative assessment
2-4 weeks before their date of surgery.
AIM
• To identify high-risk patients and alleviating the risk factors associated
with surgery
• Decreased post-op recovery time and length of hospital stay.
• Decreased anxiety of patient related to major surgeries
STEPS OF PRE-OP ASSESSMENT
• History
• Systemic examination
• Investigations
• Pre-op treatments and counselling
• Documentation
• Valid consent
PRINCIPLES OF HISTORY TAKING
• Listen: What is the problem? (Open questions)
• Clarify: What does the patient expect? (Closed questions)
• Narrow: Differential diagnosis (Focused questions)
• Fitness: Comorbidities (Fixed questions)
Examination
• General: positive findings even if not related to the proposed
procedure should be explored
• Surgery related: Type and site of surgery, complications which have
occurred due to underlying pathology
• Systemic: Comorbidities and their severity
• Specific: For example, suitability for positioning during surgery.
General Physical Examination
• To check fitness for anesthesia & surgery.
• GPE
• Systemic:
- CVS
- CNS
- GIT
- Respiratory system
Specific Surgical Examination
• to confirm previous findings & diagnosis
• to determine severity
• to gauge extent.

• E.g. in inguinal hernia confirm it’s inguinal not femoral, reducible or


not & whether there are any signs of bowel obstruction.
Co-morbidities
• To evaluate the presence & severity of other problems.
E.g. Diabetic patient undergoing surgery needs careful examination for
sepsis , neuropathy or microvascular disease.
-His BSR needs regular monitoring
- administer insulin according to the sliding scale model
Routine Investigations
• The tests which normally performed on most patient coming to surgery:
• Full Blood Count to exclude anemia, for platelets count & to assess the
amount of blood may be needed during or after operation.
• RFTs, S/Es state of dehydration & renal insufficiency
• LFTs Alb & Protein guide to nutritional status
• INR clotting problems
• ECG Cardiac evaluation
• Chest Radiography
• HBsAg , HBV & HIV testing.
Other Investigations
• Urinalysis: used for determination of renal function, inflammation,
infection & metabolic disorders.
• Pregnancy Test: ( B- HCG )
• BSR : Diabetes
• Blood gas analysis: Occ. required
Assessment of psychological needs
• Emotional state of the patient
• Level of understanding
• Coping strategies
• Support system
• Assess cultural needs
Specific Pre-op problems
C.V.S
• Hypertension ( B.P >160 systolic or >95 diastolic then surgery should
be deferred till control of BP)
• IHD / Recent MI = No Surgery till 6 months
• Arrhythmias= administer anti-arrhythmics
• Cardiac failure= restrict fluids
• Anemia & Blood transfusion = consider transfusion if Hb% < 8g/dl
• Prosthetic valves = pre-op antibiotics
• Hx of heart disease/age>65 – Echo is advised
Respiratory System
• Infections
• Asthma
• COPD
• Pulmonary Fibrosis
• If hx of resp illness or age> 65- adv PFTs
 Stop smoking 4 weeks before+ continue inhalers
Avoid respiratory suppressants
• GIT
• Malnutrition
• Obesity

Nutritional support is required - a minimum of 2 weeks prior to surgery


 Extra measures – obese patients. BMI>30kg/m2 inc risk of thrombosis.
 NPO+ Enema to decrease risk of regurgitation/aspiration of gastric
contents + contamination with fecal contents
• Genitourinary System
• Renal impairment
• UTI

Categorize – Pre-renal / Renal & Post-renal; manage accordingly


(diuretics/dialysis etc)
Start antibiotics – UTI Care taken – maintain good urine output
Coagulation disorders
• Drugs X clotting cascades
• Acquired Coagulopathy
• Thrombophilia

Thromboprophylaxis for High risk groups / Stopping of anticoagulant


drugs
 Complex bleeding disorders – consult hematologist
Stop the use of OCPs and HRT 6 wks prior
If Pt is on Anticoagulants
• Warfarin should be stopped 5 days prior. Heparin should be started
once INR <1.5.
• Heparin should be stopped 2 days prior to surgery
• After surgery, both, Warfarin and heparin should be started then Hep
discountinued.
• For emergency surgeries, use Vitamin K
• For more rapid correction, use FFPs and prothrombin complex
The Airway Examination
• The airway examination will typically be covered during the anaesthetist’s
assessment of the patient but is always good practice to assess during the
preoperative assessment. Look at the face for any obvious facial abnormalities.
Particularly, do they have a receding mandible (retrognathia)? This could cause
difficulties during airway insertion.

• Ask the patient to open their mouth and assess:


• Their degree of mouth opening (favourable if inter-incisor distance is above 3cm).
• Their teeth, mainly do they have teeth? If so, what is their dentition like? Are any
teeth loose?
• Their oropharynx. Ask the patient to maximally protrude their tongue. A
Mallampati classification, which correlates with difficulty of intubation, can be
assessed.
• Lastly, assess the neck. Ask the patient to flex, extend and laterally flex the neck
to see their range of movement. Then, ask the patient to maximally extend their
neck and measure the distance between the thyroid cartilage and chin (the
thyromental distance); if this is less than 6.5cm (~3 finger breadths), it indicates
that intubation may be difficult.
Remote infection
• Sources of bacteremia
Artificial material – Jt replacement surgery /
arterial grafting
Infected toes / teeth

Prophylactic antibiotics best administered just


prior to induction.
Documentation
• History – presented logical manner
• Investigations
• Drug chart – routine / prophylactic
• Take consent
• Complete the check list
Check list for pre-op patients
1. File
2. History
3. Labs
4. CXR
5. ECG
6. Anesthesia clearance
7. Blood Arrangement
8. Consent
9. N/A medicines
Thank you 