slide

1. Preoperative evaluation and
preparation
Mahendratama P. Adhi
SMF Anestesiologi RS Ulin Banjarmasin

2. The preoperative evaluation consists of
gathering information about the patient and
formulating an anesthetic plan. The overall
objective is reduction of perioperative
morbidity and mortality.
Inadequate preoperative planning and errors in patient
preparation are the most common causes of anesthetic
complications.
Anesthesia and elective surgery should not proceed until the
patient is in optimal medical condition.

3. Patient data
Doctor – patient relationship
Anesthetic plan
Patient consent
Preoperative evaluation and
preparation

4. Review of Patient Data
 Medical record
 Interview History : history of underlying
disease, medication, functional capacitance,
previous anesthetic history, family history,
smoking & alcoholic use, review of system,
psycological support
 Surgical condition :
- condition & symptom of disease
- surgical procedure
- position of procedure

5. Physical Examination
 Vital signs
 General appearance
 Respiratory system
 CVS system
 Abdomen
 Extremities and spine
 Neurologic system
 Airway evaluation  anticipate difficult
intubation & its management

6. Laboratory Data
 Value of testing
 Risk and costs benefits
 Preoperative testing: base on indication
 Hematological studies : Hct/Hb, Plt ,
coagulation factor
 Serum chemistry studies : BUN, Creatinin,
SGOT-SGPT, Albumin, Electrolite, Glucose
 ECG, Chest radiography, pulmonary
function tes

7. Hematological & serum chemistry studies
are routine while ECG & chest x-ray for
patient over than 40 y.o. or indicated
Hb 7 gr/dl for young & healthy patient
undergoing minimal risk surgery, Hb > 10 gr/dl
over than 40’s, children, CAD, undergoing high
risk surgery
Platelet count within normal limit (150.000-400.000)
but for urgent or emergency procedure > 70.000
without any clinical spontaneus bleeding

8. Coagulation factor ; PT & APTT within normal
limit or if the value lengthened, not over than 1.5
times than control value
Can be corrected with given of Vit K and FFP
Liver function test not over 5 times than normal
value
Creatinin not over than 5
If over than 5 should be corrected (given of
medication or/and RRT)
Electrolyte disturbance with any clinical signs must
be corrected

9. Specific test:
 Cardiac evaluation:
exercise stress test
thallium scan
echocardiogram
 Pulmonary evaluation:
lung function test
spirometry
arterial blood gas

10. Medical consultation
 To define patient’s condition
 To optimize patient’s medical condition and
future management before surgery
Consent form
Informed consent involves :
 discussing anesthetic management plan,
alternatives
 potential complication

11. Record Preoperative form
ASA physical Classification
 Class1 normal healthy patient
 Class 2 A patient with mild systemic disease and no
functional limitations
 Class 3 A patient with moderate or severe systemic
disease that results in some function limitation
 Class 4 A patient with severe systemic disease that is
threat to life and functionally incapicitating
 Class 5 A moribund patient who is not expected to
survive 24 hours with or without surgery
 (Class 6 A brain-dead patient whose organs are being
harvested)
 E for Emergency case

12. ASA Classification & preoperative
mortality rates
Class Mortality Rate
1 0.06 – 0.08 %
2 0.27 – 0.4 %
3 1.8 – 4.3 %
4 7.8 – 23 %
5 9.4 – 51 %

13. NPO Guideline
 NPO 6-8 hr. before surgery
 Clear liquid diet for 2 hr.
Children
 Clear liquid 2 hr
 Breast milk 4 hr
 Infant formula 6 hr
 solid diet 8 hr.
Guideline used for patient with no problem
with gastric emptying time

14. Perioperative Cardiovascular Evaluation for
Noncardiac Surgery
 History – angina, recent or past MI, HF,
symptomatic arrhythmias, presence of pacemaker or
ICD
 Physical Examination – general appearance, rales,
elevated JVP, carotid and other arterial pulses, S3
gallop, murmurs
 Comorbid Diseases
 Pulmonary
 Diabetes Mellitus
 Renal Impairment
 Hematologic Disorders
 Ancillary Studies - ECG almost always indicated,
blood chemistries and chest X-ray based on history
and physical findings
General approach to the patient

15.  Clinical of chest pain,heart failure and arrhythmia
should be treated before elective surgery
 Interval between MI time and surgery less than 6
month is more likely with reinfarction
 Perioperative cardiovascular risk :
clinical predictors
surgical procedure
exercise tolerance

16.  Major
 Unstable coronary syndromes
 Decompensated CHF
 Significant Arrhythmias
 Intermediate
 Mild angina pectoris
 Prior MI
 Compensated or prior HF
 Diabetes Mellitus (particularly
taking insulin)
 Renal insufficiency
 Minor
 Advanced Age.
 Abnormal ECG.
 Rhythm other than
sinus.
 Low functional
capacity.
 History of stroke.
 Uncontrolled systemic
hypertension
Clinical Predictors of Increased Perioperative
Cardiovascular Risk

17. Surgical Procedures of Increased Perioperative
Cardiovascular Risk
 High: Emergency major (particularly in elderly
patient), vascular surgery, prolong operation with
large fluid shifts and/or blood loss
 Intermediate: carotid endarterectomy,head and neck
surgery, intraperitoneal & intrathoracic surgery,
orthopedic surgery, prostate surgery
 Low: endoscopic procedure, breast surgery,
superficial procedure, cataract surgery

18. 4 METs: walk at 6 km/hr, run short distance, heavy
work around house, golf, bowling, dancing
Exercise Tolerance
The metabolic equivalent, or MET, is defined as the ratio of a
person's working metabolic rate relative to the resting
metabolic rate.
Functional capacity is defined as :
poor (<4 METS),
moderate (4–7METS),
good (>7–10METS) ,
based on evaluation of the patient’s daily activity.

20. Suplemental Preoperative Evaluation
Noninvasive testing in preoperative patients indicated if 2 or more of
following present:
 Intermediate clinical predictors (Canadian Class I or II angina, prior
MI based on history or pathological Q waves, compensated or prior
HF, or diabetes)
 Poor functional capacity (<4 METs)
 High surgical risk procedure (emergency major surgery*, aortic
repair or peripheral vascular, prolonged surgical procedures with
large fluid shifts or blood loss)
* Emergency major operations may require immediately proceeding to surgery
without sufficient time for noninvasive testing or preoperative interventions.

21. No further preoperative
testing recommended
Preoperative angiography
ECG ETT
Exercise echo or
perfusion imaging‡**
Pharmacologic
stress imaging
(nuclear or echo)
Dipyridamole or
adenosine perfusion
Dobutamine stress echo
or nuclear imaging
Other (eg, Holter
monitor, angiography)
Yes
Prior symptomatic arrhythmia
(particularly ventricular tachycardia)?
Borderline or low blood pressure?
Marked hypertension?
Poor echo window?
No
Yes
Prior symptomatic
arrhythmia
(particularly ventricular
tachycardia)?
Marked hypertension?
Bronchospasm?
II AV Block?
Theophylline dependent?
Valvular dysfunction?
No
No
Resting ECG
normal?
Patient ambulatory and
able to exercise?‡
Yes
No
YesYes
Indications for angiography?
(eg, unstable angina?)
Yes
Yes
No
No
*Testing is only indicated if the results will
impact care.
†See Table 1 for the list of intermediate
clinical predictors, Table 2 for thermetabolic
equivalents, and Table 3 for the definition of
high-risk surgical procedure.
‡Able to achieve more than or equal to
85% MPHR
** In the presence of LBBB, vasodilator
perfusion imaging is preferred.
2 or more of the following?†*
1. Intermediate clinical predictors
2. Poor functional capacity (less than 4
METS)
3. High surgical risk

22.  Patient risk for MI postop
DM
Peripheral vascular disease
HT
Tobacco used
Hypercholesterolemia
 Risk associated with surgical influence decision to
make further test
 Perioperative morbidity may be decreased with
beta blocker
 Continue medication except anticoagulant or
antifibrinolytic: aspirin,warfarin,ticlopidine etc.
 Digitalis : discontinue except in severe arrhythmia

23. Perioperative of Hypertension
Category Systolic mmHg Diastolic mmHg
Optimal < 120 and < 75
Normal < 130 and < 85
Mild HTN 140-159 or 90-99
Moderate 160-179 or 100-109
Severe > 180 or > 110
Isolated SBP HTN > 140 and < 90
Pulse Pressure > 65mmHg
Orthostatic changes Hyper response > 20 mmHg
Hypo response < 20 mmHG
Classification

24. Hypertension
 History of end organ damage: cardiac
ischemia, renal, neurological
 Elective surgery should be delayed if DBP ≥
110 mmHg with or without new onset of
headache but if no sign of end organ damage
surgery or LVH may be proceed
 In DM keep DBP < 90mmHg

25. End Organ Damage & Perioperative Outcome
 Occult CAD (Q wave on ECG)
 CHF (symptoms and signs)
 LVH (ECG voltage criteria)
 Renal insufficiency (creatinine>2.0)
 Cerebrovascular disease (hx of CVA and
TIA)

26. Treatment
 Aggressive treatment associated with reduction
in long term risk
 Generally, antihypertensive drug should be
continued during the perioperative peroid.
 Abrupt discontinuation of β-blocker
→perioperative tachycardia
 Withdrawal of clonidine →rebound HTN
 ACEI and Angiotensin II inhibitor →held
in the morning of surgery

27. Perioperative of Pulmonary Disease
 History of reactive airway Asthma
 Frequency, reversible of symptoms, interval,
last attack, history of steroid used
 Optimize good condition before elective
surgery
 COPD:new onset of bronchospasm,dyspnea
and reduced exercise tolerance should be
indicated to delay elective surgery
 Recent URI is controversial , elective surgery
should be delayed several weeks

28.  Continue medication
 Aerosol medication before surgery
 Risk reduction of pulmonary complication
 Smoking cessation
 Education of lung expansion maneuver and deep
breath exercise(incentive spirometry)
 for postop
 Treatment of obstruction
 Antibiotic
 Hydration

29.  Smoking cessation
 24 hr: decrease carboxyhemoglobin
 2-3 day: increase ciliary function
but increase secretion
 1-2 wk: decrease secretion
 4-8 wks: decrease postop pulmonary complication
In TB patient, should be undertreatment min 2 weeks
and without any clinical sign of coughing

30. Perioperative of Diabetes Mellitus
General approach to the patient
 Current medication
 Progression of end organ damage
atherosclerosis : risk for silent MI
 Autonomic dysfunction
 Hyperglycemic condition
 Risk for joint stiffness: TM joint
 Discontinue medication day of surgery

31. Preoperative Evaluation
 Operative risk assessments
 Routine risk factors: Cardiac, Pulmonary, Renal,
Hematologic
 Diabetes-related risk factors: Macrovascular,
Microvascular, Neuropathic complication
 Diabetes therapeutic regimen
 Reestablish correct diagnostic
 Pharmacological regimen
 Meal plan
 Activity level
 Hypoglycemia
 Anticipated surgery
 Type of surgical procedure
 Inpatient or outpatient
 Type of anesthesia
 Start time
 Duration of procedure

32.  In general, the goal for glucose control
during surgery is to maintain the glucose
level between:
 150-200 mg/dl
Jacober and Sower. Arch Intern Med 159: 2405-2411, 1999
 120-180 mg
Dagogo-Jack and Alberti. Diabetes Spectrum 15: 44-48, 2002
Glycemic Goal During Surgery

33.  Stop OAD 1-3 day
 Minor surgery: periopertive hyperglycemia
(BG > 200 mg/dl)RI 4-10 U
 Major surgery or poorly controlled
diabetes  insulin infusion + glucose
T2DM treated with OAD

34.  Minor surgery
 Major surgery
 Subcutaneous insulin regimens
 Intravenous insulin regimens
Insulin treated patients

35. Short procedure
early morning Delay diabetes regimen
Oral agents Hold oral agents
Single dose insulin 2/3 total daily dose
Short procedure 2 or 3 doses of insulin ½ total morning dose
Late morning
MDI 1/3 morning dose
Insulin pump basal rate only

36. Fig. Summary of perioperative management recommendation
based on therapeuitic regimen and complexity and scheduling of
the operative procedure. MDI=multiple doses of short acting
insulin2
Jacober and Sower. Arch Intern Med 159: 2405-2411, 1999
Oral agents Hold oral agents
Single dose insulin 2/3 total daily dose
Short procedure 2 or 3 doses of insulin ½ total morning dose
afternoon
MDI 1/3 morning dose
Insulin pump basal rate only
Oral agents Hold oral agents
Complex
Procedure
Insulin Continuous IV insulin

37.  Prepare a 0.1 unit/ml solution by adding 25 units RI to 250 ml normal saline
 Flush 50 ml of insulin solution through infusion tubing to saturate nonspecific
binding sites
 Set initial infusion rate (generally, 0.5 unit/h [5ml/h] for thin woman; 1.0 unit/h
[10ml/h] for other)
 Adjust infusion rate according to bedside blood measurement as follows:
Blood glucose (mg/dl) Insulin infusion rate
<80 Check glucose after 15 min*
80-140 Decrease infusion by 0.4 unit/h (4 ml/h)
141-180 No change
181-220 Increase infusion by 0.4 unit/h (0.4 ml/h)
221-250 Increase infusion by 0.6 unit/h (0.6 ml/h)
250-300 Increase infusion by 0.8 unit/h (0.8 ml/h)
>300 Increase infusion by 1 unit/h (1 ml/h)
*Regimen assume separate infusion of glucose at ~ 5-10 g/h and hourly blood glucose monitoring.
Extremely high or low glucose value should be confirmed with an immediate repeat measurement. Intravenous
boluses
of dextrose (50%) or supplemental regular insulin can be used for paid correction but are rarely necessary

38. Perioperative of Thyroid Disease
 Clinical manifestation of hyperthyroid or
hypothyroid
 Hyperthyroid: palpitation, weight loss, heat
intolerance, moist skin  thyroid strom
 Hypothyroid: bradycardia, cold intolerance,
slow mental function  hypothermia,
hypoventilation

39. LABORATORY TESTING STRATEGY for THYROID
DYSFUNCTION
THRYOID DISEASES
OVERT CLINICAL
MANIFESTATION
MINIMAL
CLINICAL
MANIFESTATION
TSHs TSHs + FT4
HYPOTHYROIDISMHYPERTHYROIDISM
TSHs + FT4 TSHs + FT4
HYPERTHYROIDISM HYPOTHYROIDISM
TSHs TSHs
SUBCLINICAL HYPOTHYROIDISM: normal Free-T4, high TSHs
SUBCLINICAL HYPERTHYROIDISM: normal Free-T4, low TSHs
History taking &
physical examination

40. Preoperative Evaluation
 Sign & symptoms of hyper or
hypothyroidism
 Cardiovascular performance
 ECG
 Thorax radiography
 Free T4

41. Preoperative Management
 Patients with thyrotoxicosis must be treat with PTU
(100-300 mg/day) or metimazol (10-30 mg/day) +
propanolol 10-80 mg/day, until euthyroid condition
 Add potasium iodide (10-15 drops/day) 10 days before
surgery
 Patient with thyrotoxicosis who going to operative
procedure for non thyroid disease can be treat with
propranolol 2-10 mg/iv or 40 mg/p.o (total dose 160-
240 mg/d orally) every 4-6 hours, until pulse rate <90.
Iodide solution 30 drops plusPTU or metimazole

42. With hyperthyroid
Surgical approach
Thyroid illness Non Thyroid illness
Without
hyperthyroid
With hyperthyroid Without
hyperthyroid
Elective
surgery
Urgent
surgery
Treat
hyperthyroidism
• β-blocker
• KI solution
• Tionamide
operative
euthyroid

43. Perioperative in Renal Disease
 Kidney Failure
 Kidney Disease
Kidney failure
 Kidney failure occurs when the kidneys partly or
completely lose their ability to carry out normal functions.
 This is dangerous because water, waste, and toxic
substances build up that normally are removed from the
body by the kidneys.
 It also causes other problems such as anemia, high blood
pressure, acidosis (excessive acidity of body fluids),
disorders of cholesterol and fatty acids, and bone disease in
the body by impairing hormone production by the kidneys

44. Chronic kidney disease
 when one suffers from gradual and usually
permanent loss of kidney function over time.
 This happens gradually over time, usually
months to years
 Chronic kidney disease is divided into five
stages of increasing severity
 Mild kidney disease is often called renal
insufficiency.
 Stage 5 chronic kidney failure  end stage
renal disease

46.  History and physical examination
 The comorbidities of CRF
 Sign and symptom of uremia, fluid overload and
inadequate dialysis.
 Laboratory :
electrolyte conc, acid-base status, urea and
creatinine levels, hematocrit, platelet count
and coagulation
 Chest radiography
pulmonary edema or pleural effusion
 E C G
myocardial ischemia
electrolyte imbalance.
Preoperative Evaluation and Preparation

47. Hyperkalaemia
- > 5 mmol/L
- > 5,5 mEq/L 􀃆contraindication to elective
surgery because tissue trauma and cell death 
increased potassium to life-threatening levels.
Therapy of hyperkalemia :
- 5 – 10 ml 10% Ca-gluconate IV over 3 min,
can repeat in 5 min
- 3 – 5 mL 10% Ca-chloride IV over 3 minute
- 10 U insulin in 500 mL 20% Dext
- 1-2 mmol/kg Na-bicarbonat iv over 5 – 10 menit
- Nebulised salbutamol 2,5 – 5 mg will assist in
moving potassium into the cells.

48. Haematological function :
- Chronic anaemia
- Unless the patient has ischemic heart dis.
Hb level may be maintained 7 – 8 g/dl.
- Th: erythropoietin or Transfusion
- Correction of anemia helps to improve
platelet dysfunction
- Platelet dysfunction :
- Desmopresin or cryoprecipitate
- Estradiol􀃆effective in the treatment of
platelet dysfunction.

49. Indication for Renal Replacement Therapy.
- Oliguria (urine output < 200 mL/12 hr)
- Anuria (urine output < 50 mL/12 hr)
- Hyperkalemia (K > 6,5 mEq/L)
- Severe acidemia (pH < 7,1)
- Azotemia (urea > 180 mg/dL)
- Pulmonary edema
- Uremic encephalopathy
- Uremic pericarditis
- Uremic neuropathy/myopathy
- Severe dysnatremia (Na > 160 or < 115 mEq/L)
- Hyperthermia

50. Dialysis :
- ESRD  GFR < 12 mL/min
- 12 – 24 hours before to elective surgery
(minimum heparinisation)
-normovolemic,
- to tolerate fluid loads – surgery
- normal electrolyte concentrations.
- Hypovolemia hemodynamicinstability.
- Fluid over load or life-threatening
hyperkalemia.