Pre operative assessment / PAC

Pre operative assessment is vital and most important in carrier as anaesthesiologist

1. Pre Anaesthetic ClinicPre Anaesthetic Clinic
Dr. P.Sivaraj MD DA
Assistant professor
Dept of Anaesthesiology, GVMC
Govt Villupuram Medical College and Hospital.

2. IntroductionIntroduction

3. Definition Definition
The process of clinical assessment that
precedes the delivery of anaesthesia care

4. Goal Goal
Anxiety
Plan in intervention and optimiz
Facilitate early normalcy
Improve out come
Efficient and cost effective Care
Consent
Option in Pain Control
Determine appropriate test
Discuss risk
Practice advisory for preanesthesia evaluation: a report by the
American Society of Anesthesiologists Task Force on Preanesthesia
Evaluation.American Society of Anesthesiologists Task Force on
Preanesthesia Evaluation Anesthesiology. 2002 Feb; 96(2):485-96.
 Roizen MF, Foss JF, Fischer SP. Preoperative evaluation. In: Miller
RD, editor. Anesthesia. 5th ed. Vol. 1. New York: Churchill-
Livingstone; 2000. pp. 824–83.
Cancellation in elective orthopaedic surgery. Koppada B, Pena M,
Joshi A Health Trends. 1991; 23(3):114-5 .

5. Uses Uses
Educate the patients
Organize the resources
Informed consent
Formulate plans for intra operative care
Perioperative pain management
Post operative recovery

6. I. Problem Identification
II. Risk Assessment
III. Preoperative Preparation
IV. Plan of Anesthetic Technique

The purpose of the preoperative visit:The purpose of the preoperative visit:

7. I. Problem IdentificationI. Problem Identification
● Case History
●Physical examination
●Laboratory investigation

8. I. Problem IdentificationI. Problem Identification
1.h/o present illness
•Cardiovascular : hypertension ; ischemic , valvular or congenital heart
disease; CHF or cardiomyopathy, , arrhythmias
•Respiratory : smoking; COPD; restrictive lung disease; altered control of
breathing (obstructive sleep apnea, CNS disorders, etc.)
•Neuromuscular : raised ICP ; TIA's or CVA's; seizures; spinal cord
Injury; disorders of NM junction e.g myasthenia gravis, muscular dystrophies
,MH
•Endocrlne : DM; thyroid disease; pheochromocytoma; steroid therapy
•GI - Hepatic : hepatic disease; gastresophageal reflux
•Renal : renal failure

9. I. Problem IdentificationI. Problem Identification
•Hematologic : anemias; coagulopathies
•Elderly , Children, Pregnancy
2 h/o past illness
Chronic diseases
Jaundice
•Medications and Allergies
•Prior Anesthetics
•Alcohol, drugs, smoking, activities and exercise tolerance
3. Family history

10. Physical Examination:Physical Examination:
General & Local examination
Evaluation of :
•Upper airway
•Respiratory system
•Cardiovascular system
•Vital signs

11. Preoperative Laboratory Testing:Preoperative Laboratory Testing:
only if indicated from the preoperative history and physical only if indicated from the preoperative history and physical
examination.examination.
"Routine or standing" pre operative tests should be discouraged"Routine or standing" pre operative tests should be discouraged
-CBC anticipated significant blood loss, suspected
hematological disorder (eg.anemia, thalassemia, SCD), or recent
chemotherapy.
-Electrolytes diuretics, chemotherapy, renal or adrenal
disorders

12. Investigations Investigations
-ECG age >50 yrs ,history of cardiac disease, hypertension, peripheral
vascular disease, DM, renal, thyroid or metabolic disease.
-Chest X-rays prior cardiothoracic procedures ,COPD, asthma, a
change in respiratory symptoms in the past six months.
-Urine analysis DM, renal disease or recent UTI.
-Echocardiography
-Indirect laryngoscopy
-Pulmonary function tests

14. Should routine pre-operative testing be
abandoned?
Klein AA, Arrowsmith JE Anaesthesia. 2010
Oct; 65(10):974-6.

15. The preoperative evaluation: use
the history and physical rather
than routine testing.
Michota FA, Frost SD Cleve Clin J Med. 2004
Jan; 71(1):63-70.

16. ASA Physical Status Classification System
For emergent operations, you have to add the letter ‘E’ after the classification.

17. Patient assessment Patient assessment
ASA physical status
Cardiac risk
1.Goldman multifactorial cardiac risk index
2.Detsky’s multifactorial index
3.Revised Cardiac Risk Index

19. II. Risk AssessmentII. Risk Assessment
Components for evaluating perioperative risk:
•Patient's medical condition preoperatively
•Type or extent of the surgical procedure
•Risk from the anesthetic
““Most of the work, however, addresses the operative riskMost of the work, however, addresses the operative risk
according to the patient's preoperative medical status”according to the patient's preoperative medical status”

20. Types of surgical proceduresTypes of surgical procedures
Class A
Class B
Class C
Physiology, morbidity, blood, invasive
monitor, post op icu

21. III. Preoperative PreparationIII. Preoperative Preparation
Anesthetic indications:
Anxiolysis, sedation and amnesia. e.g.
benzodiazepine(diazepam ,lorazepam)
Analgesia e.g. narcotics
Drying of airway secretions e.g. atropine, glycopyrrolate
 Reduction of anesthetic requirements ,
 Facilitation of smooth induction
Patients at risk for GE reflux : ranitidine ,metoclopramide ,
sodium citrate

22. Preoperative preparationsPreoperative preparations
Surgical indications:
- Antibiotic prophylaxis for infective endocarditis.
- Prophylaxis against DVT for high risk patients :
low-dose heparin or aspirin, intermittent calf
compression, or warfarin

23. Preoperative preparationsPreoperative preparations
Co-existing Disease indications:
• Some medications should be continued on the
day of surgery e,g Beta -blockers, thyroxine, anti
hypertensive, nitrates ,antiepileptic,
bronchodilators
• Others are stopped e.g oral hypoglycemics,
Tricyclic ani depressant inhibitors and MAO
inhibitors
•Steroids within the last six months may require
supplemental steroids

24. INGESTED MATERIAL
MINIMUM FASTING PERIOD,
APPLIED TO ALL AGES (hr)
Clear liquids 2
Breast milk 4
Infant formula 6
Nonhuman milk 6
Light meal (toast) 6
Fasting Recommendations Fasting Recommendations

25. IV. Plan of Anesthetic TechniqueIV. Plan of Anesthetic Technique
1.Is the patient's condition optimal?
2.Are there any problems which require consultation or
special tests? “Please assess and advise “
3. Is there an alternative procedure which may be more
appropriate?
4. What are the plans for postoperative management of the
patient?
5. What premedication if any is appropriate?

26. Finally, we plan our anesthetic technique :
1.Local
2. Regional anesthesia
2. General anesthesia
3. Combination

28. Cancelling casesCancelling cases
Control temptation of taking up every
cases
Inadequate preparation
Communication

30. “The surgeon should not demand or insist on a
particular technique or the capability of the
anaesthesiologist to manage the particular
technique” – John Alfred Lee

31. BENEFITS OF AN EFFECTIVE
FUNCTIONING
PREANAESTHETIC CLINIC

32. Early anesthesia evaluation of the
ambulatory surgical patient: does it
really help?
Twersky RS, Lebovits AH, Lewis M, Frank
D J Clin Anesth. 1992 May-Jun; 4(3):204-7.

33. Recommendations Recommendations
 ASA Task Force has recommended that
preanaesthesia evaluations should be
performed prior to the day of surgery for
patients with high severity of disease and/or
undergoing procedures of high surgical
invasiveness
Practice advisory for preanesthesia evaluation: a report by
the American Society of Anesthesiologists Task Force on
Preanesthesia Evaluation.American Society of
Anesthesiologists Task Force on Preanesthesia
Evaluation Anesthesiology. 2002 Feb; 96(2):485-96.

34. Reduction in excessive Reduction in excessive
preoperative testingpreoperative testing
60–75% of preoperative tests ordered are
medically unnecessary.
Kaplan EB, Sheiner LB, Boeckmann AJ, Roizen MF,
Beal SL, Cohen SN, Nicoll CD JAMA. 1985 Jun 28;
253(24):3576-81.

36. •Existing literature suggests that 30-60% of abnormalities
discovered on routine preoperative tests are ignored.
Roizen MF. More preoperative assessment by physicians
and less by laboratory tests. N Engl J Med 2000;342:204-
205.
•Given this fact, routine preoperative testing without
documentation of abnormalities actually may lead to more
medico-legal risk.
•In general, it is safe to use test results that were performed
and were normal within the previous four months, given that
no change has occurred in the patient's clinical status.
•One study reported that only 0.4% of such tests repeated at
the time of surgery were abnormal and could have been
predicted by the patient's history.

Smetana GW, Macpherson DS. The case against
routine preoperative laboratory testing. Med Clin
North Am 2003;87:7-40.

37. REDUCTION IN REDUCTION IN
SUBSPECIALTY CONSULTSSUBSPECIALTY CONSULTS
The effect of alterations in a preoperative
assessment clinic on reducing the number
and improving the yield of cardiology
consultations.
Tsen LC, Segal S, Pothier M, Hartley LH,
Bader AM Anesth Analg. 2002 Dec;
95(6):1563-8,

38. Enhanced operative room Enhanced operative room
functioningfunctioning
Value of preoperative clinic visits in
identifying issues with potential impact on
operating room efficiency.
Correll DJ, Bader AM, Hull MW, Hsu C,
Tsen LC, Hepner DLAnesthesiology. 2006
Dec; 105(6):1254-9;

39. References References
Development and effectiveness of an
anesthesia preoperative evaluation clinic
in a teaching hospital.

Fischer SP Anesthesiology. 1996 Jul;
85(1):196-206.

40. References References
Economic benefits attributed to opening
a preoperative evaluation clinic for
outpatients.

Pollard JB, Zboray AL, Mazze RI Anesth
Analg. 1996 Aug; 83(2):407-10.

41. References References
Telemedicine versus face to face patient
care: effects on professional practice and
health care outcomes.
Currell R, Urquhart C, Wainwright P,
Lewis R Cochrane Database Syst Rev.
2000; (2):CD002098.
Assessing telemedicine: a systematic
review of the literature.
Roine R, Ohinmaa A, Hailey D CMAJ. 2001
Sep 18; 165(6):765-71.

42. References References
Cost-effective preoperative evaluation
and testing.
Fischer SP Chest. 1999 May; 115(5
Suppl):96S-100S.
Preoperative testing: moving from
individual testing to risk management.
Pasternak LR Anesth Analg. 2009 Feb;
108(2):393-4.

43. References References
More preoperative assessment by
physicians and less by laboratory tests

Roizen MF N Engl J Med. 2000 Jan 20;
342(3):204-5.