preanesthetic evaluation, NPO guidelines, ASA physical status , medication management , anesthesia history taking

1. Preanesthetic assessment
Dr. Raman Ghimire
Department of Anesthesiology

2. INTRODUCTION
Preanesthetic assessment
Preanesthesia evaluation
Pre-anesthesia checkup (PAC)
Preanesthesia
• Process of clinical assessment that precedes the delivery of
anesthesia care for surgery and for nonsurgical procedures.
• Patient’s medical records, interview, physical examination &
investigations
• First introduction of anesthesia to the patient
• Reduces patient anxiety before surgery and may even decrease
postoperative pain and length of hospital stay.

3. GOALS
1. Evaluation of patient's general health
(+ optimisation if necessary)
2. Anticipation of possible complications
(+ planning to avoid them)

4. OBJECTIVES
• Doctor patient relationship
• Patient data
• Anesthetic plan
• Patient consent

5. STEPS OF PREOPERATIVE VISIT
1. Problem identification
2. Risk assessment
3. Preoperative preparation
4. Plan of anesthetic technique.

6. HISTORY
1.Identification of the Patient
Name: Age: Sex:
Review file
Pre operative Diagnosis:
Planned Operation :
Mode of anesthesia : RA/LA/GA

7. 2.History of previous anaesthesia .
• Allergy to drugs
• PONV
• Expose to Halothane within 3 months prior to
Surgery
• Anesthesia awareness
• Difficult intubation
• Delayed emergence

8. 3.Past Medical history :
• DM, HTN,COPD,CAD,thyroid disorder….
• Regular medications
• Previous surgeries ; date: type of anesthesia:
4.Personal History:
• smoking, alcohol, drug abuse
5.Family history:
Problems with anesthesia in family
(Pseudocholinesterase deficieny and malignant hyperpyrexia)

9. 6. Menstrual history : ? Pregnancy LMP:….
7. Review of system:
 Respiratory :
URT:cough &cold
LRT: SOB
 Cardiac
 CNS
 GI
Oral cavity : dentures, loose teeth ,capped teeth
P/A:
 Urogenital

10. EXAMINATION
A.General Examination
Weight : BMI:
PILCCOD
VITAL SIGNS:
SPO2
Pulse
B.P
Temperature
RR
B.Systemic Examination
• Chest
• CVS
• P/A
• CNS
C.Local examination
 Spine : deformity
 Nasal cavity:
deformity,obstruction
 Oral cavity :
teeth ,tongue,dentures
 Peripheral venous access

11. AIRWAY ASSESSMENT:

12. “LEMON” SCORING

13. AIRWAY ASSESSMENT CUE-CARD

14. UPPER LIP BITE TEST
• class I : lower incisors can bite the upper lip above the vermilion line
• class II : lower incisors can bite the upper lip below the vermilion line
• class III : lower incisors cannot bite the upper lip

15. MALLAMPATI SCORE

16. INVESTIGATIONS
Basic Investigations
• CBC: Hb,TC/DC,
• ABO Rh typing
• RBS
• Urea , Creatinine , Na+ ,K+
• PT/INR
• Urine RME
• CXR
• ECG
• Serology
Other (if needed)
• Echocardiography
• TFT
• HbA1c
• BT/CT , aPTT
• LFT
• PFT
• ……..

17. RISK ASSESSMENT

19. • ASA classification does not include the nature of procedure in predicting
perioperative morbidity and mortality.
• It only includes patient-based morbidity rather than type of surgery

20. ASA Fasting Guidelines
Water ,
Fruit juice without pulp
carbonated beverages,
clear tea
black coffee,
2 hoursClear fluid
Milk
4 hoursHuman
6 hoursInfant formula
Fruits , juice with pulp,
Vegetables
6 hoursLight Foods
Fatty meals , meats
8 hoursHeavy foods

21. Medication Management
#hold 24 hrs prior surgery (major OT)
Day before OT OT day
Levothyroxine Continue Continue
CCB Continue Continue
Beta Blockers Continue Continue
ACEi/ARB Continue Hold
Diuretics Continue Hold
Metformin Hold Hold
OHA Continue Hold
Inhaled
bronchodilators
Continue Continue

22. MCQs
1. Preoperative anesthetic evaluation is likely to bring down the incidence of
all the following, EXCEPT
A. Case cancellations
B. Patient morbidity
C. Preoperative anxiety
D. Direct procedural costs
ANS : D
• Preoperative evaluation in fact includes a battery of tests and adds additional costs to
the total perioperative costs.
• However, preoperative evaluation is vital, as it recognizes patient comorbidities,
which can worsen perioperatively and cause increased patient morbidity.
• eventually lowers indirect costs that may be incurred to treat the worsening aliment,
postoperatively.

23. 2. A morbidly obese patient with a history of uncontrolled
hypertension, diabetes, who is to undergo a Emergency
Appendectomy , will be classified as an:
A. ASA II E
B. ASA III E
C. ASA IV E
D. ASA V E
ANS: B

24. 3. What would be Mallampati Grading if soft palate, hard
palate and uvula is seen in mouth opening :
A. I
B. II
C. III
D. IV
ANS: B

25. REFERENCES
• Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to
Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients
Undergoing Elective Procedures: An Updated Report by the American Society of
Anesthesiologists Committee on Standards and Practice Parameters
• Associations between ASA Physical Statusand postoperative mortality at 48 h:
acontemporary dataset analysis compared toa historical cohortThomas J. Hopkins1*,
Karthik Raghunathan1, Atilio Barbeito1, Mary Cooter1, Mark Stafford-
Smith1,Rebecca Schroeder1, Katherine Grichnik2, Richard Gilbert2and Solomon
Aronson1
• Practice Advisory for Preanesthesia Evaluation An Updated Report by the
American Society of Anesthesiologists Task Force on Preanesthesia Evaluation