pre operative assessment - investigations with pictures

1. Investigations
NIK MUHAMAD ARIFF BIN MOHD AZMI
BMS 13091713

2. Surgery Grades
Minor
• Excising skin
lesion
• Draining breast
abscess
Intermediate
• Primary repair
of inguinal
hernia
• Tonsillectomy
• Knee
arthroscopy
Major or complex
• Total abdominal
hysterectomy
• Thyroidectomy
• Colonic
resection
• Radical neck
dissection

3. Why?
Confirmation
of diagnosis
Exclusion of
alternate
diagnosis
To know the
extent of the
disease
Assessment of
fitness for
surgery
Risk to others
Medico legal
considerations

4. Full Blood Count
Major operations In elderly Anemia Ongoing blood loss
In older patients with medical diseases,
likelihood of abnormal tests is higher;
therefore more liberal testing may be
done. However using age as a criteria for
routine tests is debated and ASA physical
status and risk of surgery are considered
better predictors of surgical outcome in
elderly patients. There is growing
evidence that physiological age with
overall health condition and invasiveness
of surgery rather than chronological age
should determine the need of tests
especially ECG.
In the majority of studies,
people without anaemia had
better outcomes with
regards to mortality,
infections, length of stay and
readmission rates. One
study reported that people
with anaemia had received
more blood transfusions,
which seems to indicate a
change in management in
relation to testing.
These surgeries were
considered to be a higher
risk and more likely to
offer benefits to patients.
Are not helpful in acute
haemorrhage because
values do not change from
normal until redistribution
of interstitial fluid into the
blood plasma occurs after 8-
12 hours. Haemoglobin and
haematocrit values remain
unchanged from baseline
immediately after acute
blood loss.

5. Urea & electrolyte
Major operations > 60 years old Significant blood loss
Medications which
affect electrolyte levels
The higher prevalence of
impaired renal function in the
older population was
discussed, but it was felt that
this would be adequately
considered as this population
would be more likely to have
a higher ASA grade and
therefore be offered urea,
electrolyte and creatinine
testing.
Useful in major surgery
as a preoperative
baseline value and can
be used to measure
postoperative recovery.
Increased levels are seen
with reduced glomerular
filtration due to renal or
pre-renal disease;
bleeding into the
gastrointestinal tract;
hypercatabolic states.
Such as steroids,
diuretics, digoxin,
NSAIDs, IV fluid or
nutrition therapy

6. Electrocardiography(ECG)
> 60 years old CVS involvement Renal involvement
Cerebrovascular
involvement
Diabetes
Severe respiratory
problems
Are frequently performed in
patients aged over 50 or 60
years to screen for
asymptomatic coronary
artery disease
To assess for ischaemic
and other cardiovascular
disease
To screen for arythmias

7. Clotting screen(Platelet count, INR, Bleeding time..)
History of bleeding
diathesis
Liver disease Eclampsia
Cholestasis
Family history of
bleeding disorder
Antithrombotic/
anticoagulant agent

8. Chest Xray
Cardiac history Cardiac failure Severe COPD
Acute respiratory
symptoms
Pulmonary cancer Metastasis Pulmonary effusions Risk of TB

9. Urinalysis
Urinary infection Biliuria Glycosuria
Inappropriate
osmolality
An increased rate
of 30-day
complications in
elective general
surgery patients
with UTI
The most common
cause of
bilirubinuria
is hepatocellular
disease
Healing of wound will
take place by first
intention in the presence
of a blood sugar
somewhat above normal
with the patient showing
small amounts of sugar in
the urine.

10. Β-Human chorionic gonadotrophin (βHcg)
All women of
childbearing age
Pregnancy needs to be
ruled out

11. Blood glucose & HbA1c
Diabetes Mellitus Endocrine problems

12. Arterial blood gases
Severe respiratory
conditions
Acid-base
disturbances

13. Liver function test
Jaundice
Known or suspected
hepatitis
Cirrhosis Malignancy
Poor nutritional
reserves

14. Airway assessment
The ease or difficulty in performing airway manoeuvres can be
predicted by :
Modified Mallampati
class
Jaw protrusion Neck movement
Thyromental
distance

15. Samsoon & Young modified Mallampati
*Is performed with the
clinician sitting in front of
the patient, with the
patient’s mouth open &
tongue protruding.
*Look for loose teeth,
obvious tumours, scars,
infections, obesity,
thickness of the neck, etc.

16. The higher the grade, the higher the risk in
obtaining and securing an airway.
When more than one of the above tests is
positive, the chances of experiencing
difficulty in obtaining and securing the airway
become greater.

17. References
• Bailey & Love’s Short Practice of Surgery - 26th Edition
• NICE guideline