This document provides guidance on preoperative evaluation and preparation of patients undergoing anesthesia and surgery. It discusses performing a thorough history and physical exam to assess any medical conditions or risks that could impact anesthesia. The goals are to reduce patient risk, modify care as needed, and improve surgical outcomes. Key organ systems to evaluate include respiratory, cardiovascular, neurological, and endocrine. Relevant lab tests may be ordered depending on physical findings. The document also provides guidelines on preoperative preparation for conditions like diabetes and use of steroids to optimize patient health and safety during the perioperative period.

1. - DR. JAYAL BHAGAT
MD Anaesthesia
PDMMC ,Amaravati

2.  Anesthetic drugs and techniques have profound effects
on human physiology. Hence, a focused review of all
major organ systems should be completed prior to
surgery.
 The goals of preoperative evaluation are to reduce
patient risk and the morbidity of surgery
(with the premise that it will modify patient care and
improve outcome)

3.  This ultimately allows the anaesthesiologist to
formulate an appropriate anaesthetic plan with
contingencies to deal with patients comorbidity
associated complications and/or need to optimize
patient prior to surgery.
 It is also a medicolegal document.

4.  The process should be used to educate the patient
about anesthesia and the perioperative period, answer
all questions, and obtain informed consent.

5. History taking
“Always listen to the patient they
might be telling you the diagnosis”.
(Sir William Osler 1849 - 1919)

6. APPROACH TO THE PATIENT
 Name
 Age /sex
 Address
 Presenting complains -
 Diagnosis & proposed surgery
 h/o of presenting complains :-
 duration /severity
 mode of onset
 Progression
 Associated complaints

7.  Past illness
 Personal history
 Family history
 Drugs & allergies
 Prior surgeries and prior experience with
anaesthetics(e.g. PONV, malignant hyperthermia )
 General examination
 Systemic examination
 Lab investigation assessment

8.  Nil by mouth
 Current comorbidities(acute or chronic )
 Risk classification –ASA Physical status classification

9. medical status
ASA I normal healthy patient without organic, biochemical, or psychiatric
disease
ASA II mild systemic disease with no significant impact on daily activity
e.g. mild diabetes, controlled hypertension, obesity .
ASA III severe systemic disease that limits normal activity. Significant
impact on daily activity. Probable impact on Anesthesia & Surgery
e.g. angina, COPD, prior myocardial infarction
ASA IV SEVERE disease that is a constant threat to life or require intensive
therapy. Serious limitation of daily activity. Major impact on
Anesthesia & Surgery e.g. CHF, unstable angina, renal failure
,acute MI, respiratory failure requiring mechanical ventilation
ASA V moribund patient who is equally likely to die with or without
surgery e.g. ruptured aneurysm
ASA VI brain-dead patient whose organs are being harvested
ASA Physical Status Classification System
For emergent operations, you have to add the letter ‘E’ after the classification.

11. Respiratory system
1. Cardinal symptoms
 Cough
 Types – dry/prroductive/paroxysmal/bovine
 Sputum
 Amount
 Colour
 Consistensy
 Odour

12. Dyspnoea
• Causes –
• Physiologiacal – anemia ,exercise, mountainers
• Respiratory – asthama ,COPD,pulmonary edema
pneumothorax ,pleural effusion
• Cardiac – acute MI,cyanotic heart disease, valvular
heart dieases
• Metabolic – acidosis
• CNS – GBS, polio, myasthenia gravis

13.  Hemoptysis
 h/o smoking, tobacco use,alcohol

14. Pulmonary
 A screening evaluation should include questions
regarding the history of tobacco use, shortness of
breath, cough, wheezing, stridor, and snoring or sleep
apnea.
 The patient should also be questioned regarding the
presence or recent history of an upper respiratory tract
infection.
 Auscultation should be used to detect decreased
breath sounds, wheezing, stridor, or rales.

15. Cardiovascular system
 Cardinal symptoms
 Dyspnoea on exertion
 Chest pain
 Palpitation
 Syncope
 Cough
 Hemoptysis

16. NYHA Classification
 Class I: no limitation of physical activity; ordinary activity
does not cause fatigue, palpitations, or syncope
 Class II: slight limitation of physical activity; ordinary
activity results in fatigue, palpitations, or syncope
 Class III: marked limitation of physical activity; less than
ordinary activity results in fatigue, palpitations, or
 syncope; comfortable at rest
 Class IV: inability to perform any physical activity without
discomfort; symptoms at rest

17. Metabolic equivalent
1 Eating, working at a computer, dressing
2 Walking down stairs or in your house, cooking
3 Walking 1-2 blocks
4 Raking leaves, gardening
5 Climbing 1 flight of stairs, dancing, bicycling
6 Playing golf, carrying clubs
7 Playing singles tennis
8 Rapidly climbing stairs, jogging slowly
9 Jumping rope slowly, moderate cycling
10 Swimming quickly, running or jogging briskly
11 Skiing cross country, playing full-court basketball
12 Running rapidly for moderate to long distances

18. Other important symptoms
 Fever
 Headache
 Syncope
 Convulsions
 Constipation /diarrhoea
 Loss of weight
 H/o heartburns

19. Past illness
 h/o of Hypertension ,DM ,TB
 h/o of Drugs allergy
 h/o of surgery & exposure to anaesthesia
 Previous hospitalization

20.  Personal h/o - smoking,tobacco ,alcohol
 Family h/o – HT,DM,
• Consnguinity
• Sickle cell disease
,thalassaemia,heamophilia
•

21. General examination
 Temperature
 Pulse
 Respiratory rate
 Blood pressure
 pallor / oedema
/lymphedenopathy/icterus/cyanosis/clubbing

22. Pulmonary
 Inspection – shape of chest/ movement
• Type of breathing
 respiratory rate /rhythm
 Percussion –
 Dull note – consolidation/fibrosis
 Stony - pleural effusion
 Tympany – pneumothorax /emphysema
 Auscultation should be used to detect decreased
breath sounds, wheezing, stridor, or rales.

23. CVS inspection
 Precordium - bulging /flattened
 Apex impulse
 Dilated veins
 Palpation & percussion

24. Auscultation
Mitral area 5th intercostal space just inside the midclavicular line
Tricuspid Lower end of sternum near ensiform cartilage
aortic 2nd right intercostal space
pulmonary 2nd left intercostal space

25. Neurologic System
 A screening of the neurological system in the apparently
healthy patient can mostly be accomplished through
simple observation.
 The patient's ability to answer health history questions
practically ensures a normal mental status.
 Questions can be directed to exclude the presence of ;
 Increased intracranial pressure,
 Cerebrovascular disease,
 Seizure history,
 Preexisting neuromuscular disease,
 Nerve injuries,
 Spinal cord Injury;
 Disorders of NM junction e.g myasthenia gravis, muscular
dystrophies

26.  Power
 Tone
 Ataxia
 Involuntary movements
 Reflexes – superficial /deep

27. Predictors of difficult intubation ( 4 M )
Mallampati
Measurements 3-3-2-1 or 1-2-3-3 Patient ‘s fingers
Movement of the Neck
Malformations of the Skull
Teeth
Obstruction
Pathology

28. Class I = visualize the soft palate, fauces, uvula, anterior
and posterior pillars.
Class II = visualize the soft palate, fauces and uvula.
Class III = visualize the soft palate and the base
of the uvula.
Class IV = soft palate is not visible at all.
Mallampati

29. Measurements 3-3-2-1
3 Fingers Mouth Opening
3 Fingers Hypomental Distance. (3 Fingers between the tip
of the jaw and the beginning of the neck (under the chin)
2 Fingers between the thyroid notch and the floor of the
mandible (top of the neck)
1 Finger Lower Jaw Anterior sublaxation

30. Movement of the Neck

31. Skull (Hydro and Microcephalus)
Teeth ( protruded, & loose teeth. Macro and Micro mandibles)
Obstruction (obesity, short Bull Neck & swellings around the head
and neck)
Pathology (Craniofacial abnormalities & Syndromes e.g. Treacher
Collins, Goldenhar's, Pierre Robin syndromes)
.
Malformation of the skull

33. Treacher Collins
(mandibulofacial dysostosis)

34. Pierre Robin
( hypertelorism; and external and middle ear deformities)

35. Cardiovascular System
 When screening a patient for cardiovascular disease prior to
surgery, the anesthesiologist is most interested in recognizing
signs and symptoms of uncontrolled hypertension and unstable
cardiac disease such as ;
 myocardial ischemia,
 congestive heart failure,
 valvular heart disease, and
 significant cardiac dysrhythmias
 Exercise tolerance is one of the most important determinants of
perioperative risk and the need for further testing and invasive
monitoring.
 Inability to walk 4 blocks (1 block is100-200 meters) or climb 2
flights of stairs is defined as poor exercise tolerance.(this doubles
your risk of adverse cardiovascular outcomes)

36. Endocrine System
 Each patient should be screened for endocrine
diseases that may affect the perioperative course:
 diabetes,
 thyroid disease,
 parathyroid disease,
 endocrine-secreting tumors, and
 adrenal cortical suppression.

37. Issues Related to Surgery :
 significant blood loss;
 respiratory compromise;
 positioning

38. Laboratory Testing
 Reasonable testing
 positive finding in history and physical exam.
 need for baseline value in anticipation of significant
change due to surgery and medical intervention
 patient's inclusion in population at higher risk

40. 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,scopolamine
-Reduction of anesthetic requirements ,Facilitation of smooth induction
-Patients at risk for GE reflux :ranitidine ,metoclopramide , sodium citrate
• Surgical indications:
-Antibiotic prophylaxis for infective endocarditis.
-Prophylaxis against DVT for high risk patients : low-dose heparin or aspirin
intermittent calf compression, or warfarin.
• Co-existing Disease indications:
Some medications should be continued on the day of surgery e,g B blockers,
thyroxine. Others are stopped e.g oral hypoglycemics and antidepressants .
Steroids within the last six months may require supplemental steroids

41. 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 and clear liquids) 6
Fasting Recommendations

42. Preop preparation for DM
 Classic “Non–Tight Control” Regimen
 Aim: To prevent hypoglycemia, ketoacidosis, and hyperosmolar states.
 Protocol:
1. On the day before surgery, the patient should be given nothing by
mouth (NPO) after midnight; a 13-ozglass of clear orange juice should
be at the bedside or in the car for emergency use.
2. At 6 AM on the day of surgery, infuse a solution of intravenous fluids
containing 5% dextrose through plastic cannulas at a rate of 125
mL/hr/70 kg body weight.
3. After starting the intravenous infusion, give half the usual morning
insulin dose (and the usual type of insulin)subcutaneously.
4. Continue 5% dextrose solutions through the operative period and give
at least 125 mL/hr/70 kg body weight.
5. In the recovery room, monitor blood glucose concentrations and treat
on a sliding scale.

43.  “Tight Control” Regimen 1
 Aim: To keep plasma glucose levels at 79 to 120 mg/dL. Maintenance of
such levels may improve wound healing and prevent wound infections,
improve neurologic outcome after global or focal CNS ischemic insults,
or improve weaning from cardiopulmonary bypass.
 Protocol:
1. On the evening before surgery, determine the preprandial blood glucose
level.
2. Through a plastic cannula, begin an intravenous infusion of 5%
dextrose in water at a rate of 50 mL/hr/70 kgbody weight.
3. “Piggyback” an infusion of regular insulin (50 units in 250 mL or 0.9%
sodium chloride) to the dextrose infusion with an infusion pump
Before attaching this piggyback line to the dextrose infusion,flush the
line with 60 mL of infusion mixture and discard the flushing solution.
This approach saturates insulin binding sites on the tubing.
4. Set the infusion rate by using the following equation: Insulin (U/hr) =
plasma glucose (mg/dL)/150. (Note: The denominator should be 100 if
the patient is taking corticosteroids, e.g., 10 mg of prednisolone a day or
its equivalent, not to include inhaled steroids, or has a body mass index
of ≥35.)

44. 5. Repeat blood glucose measurements every 4 hours as needed, and
adjust insulin appropriately to obtain blood glucose levels of 100 to 200
mg/dL.
6. On the day of surgery, intraoperative fluids and electrolytes are
managed by continued administration of non–dextrose-containing
solutions, as described in steps 3 and 4.
7. Determine the plasma glucose level at the start of surgery and every 1 to
2 hours for the rest of the 24-hour period. Adjust the insulin dosage
appropriately.

45. “Tight Control” Regimen 2
 Aim: Same as for Tight Control Regimen 1.
 Protocol:
 1. Obtain a “feedback mechanical pancreas” and set
the controls for the desired plasma glucose regimen.
 2. Institute two appropriate intravenous lines.

46. Sliding scale for DM

47. Steroids in anesthetic
consideration