Preoperative evaluation,Preparation and Premedication

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Pre-operative Evaluation Preparation and
Pre-medication
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• 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.

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• If any procedure is performed without the
  patient's consent, the physician may be liable
  for assault and battery.
• The intra-operative anesthesia records serves
  many purposes. It functions as a useful
  intraoperative monitor, a reference for future
  anesthetics for that patient, and as a tool for
  quality assurance.

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Routine Pre-operative Anesthetic Evaluation

• I- History-
• 1- Current problem
• 2- Other known problems
• 3- Medication history
• 4- Previous anesthetics surgery obstetric
  deliveries.
• 5- Family history.
• 6 Last oral intake.

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• Current guidelines for fasting time
• For healthy adult with no risk of aspiration
  ( e.g. gastrointestinal obstruction,
  gastroesophageal reflux, DM due to gastroparesis,
  abdominal distention as in obesity-ascites-
  pregnancy, trauma, and drugs that cause delayed
  emptying time ). The following is recommended
• 1- For solids 8 hours.
• 2- For soft diet 6 hours.
• 3- For fluids that are not clear 4 hours.
• 4- For clear fluids 2 hours.

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• 7- Review of organ systems-
• General ( including activity level ).
• Respiratory.
• Cardiovascular.
• Renal.
• GIT.
• Hematological.
• Neurological.
• Psychiatric.
• Endocrinal.
• ..

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II- Physical Examination

• Vital signs.
• Airway.
• Heart.
• Lungs.
• Extremities.
• Neurological Examination.

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III- Laboratory Evaluation

• Hematocrite or Hemoglobin concentration -
• All menstruating women.
• All patients over 60 years.
• All patients who are likely to
  experience significant blood loss may require
  transfusion.
• Serum glucose Creatinine.
• ECG Chest X-ray.

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IV- ASA Classification
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IV- ASA Classification ( continued )
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ASA Classification preoperative mortality rates
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The Anesthetic Plan

• 1 - Pre-medication.
• 2 - Types of Anesthesia -
• General
• Local or Regional anesthesia
• Monitored Anesthesia Care
• 3 - Intra-operative management.
• 4 - Post-operative management.

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Types of Anesthesia

• General-
• Airway management.
• Induction
• Maintenance
• Muscle Relaxation

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• Local or Regional -
• Technique.
• Agents.
• Monitored Anesthesia Care -
• Supplemental Oxygen.
• Sedation.

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Intra-operative management

• Monitoring.
• Positioning.
• Fluid Management.
• Special Techniques.

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Post-operative management

• Pain control.
• Intensive Care-
• Post-operative Ventilation.
• Hemodynamic Monitoring.

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How To ? O2 Content

• O2 Content (O2 carrying capacity) ml / 100 ml
  blood 1.34 x Hb x O2 sat. (O2 carried by Hb.)
  0.003 x PaO2 (O2 dissolved in plasma) .
• Normal O2 content is 20.3 ml / 100 ml blood.
• Dissolved O2 0.3 ml /100ml blood i.e. 1.5 of
  the total O2 content.
• However in severely anemic patient with Hb of 5
  gm / 100ml, the dissolved O2 is 4.5 of the
  total O2 content in room air.

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• If the patient breathes 100 O2, the PaO2 is
  normally gt 600 mmHg ? the dissolved O2 will be
  1.86 ml /100 ml blood i.e. 21.7 of the total O2
  content.
• Also we can ? O2 carrying capacity by increasing
  Hb.
• However, better to keep Ht. around 34 .

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