The role of anesthesiologist is that of consultant to surgeon in
reference to pharmacology & physiology, as in O.T. he is supposed to
manage physiological dysfunction, pharmacological needs & medical
For this reason he should know the patient in detail.
GOAL OF PREOPERATIVE MEDICAL ASSESSMENT:
1. To reduce the morbidity of surgery.
2. To increase the quality & decrease cost of perioperative care.
3. To return the pt to desirable function as quickly as possible.
3. Anaesthetist’s visit prior to surgery helps in allaying
patient’s fear about anesthesia and surgery.
He explains the plan of anesthesia whether regional or
general & perioperative care (depending on the type of
Still inadequate preop evaluation is one of the top
three causes of lawsuit against anesthesiologist.
4. HISTORY TAKING:
1. H/O Presenting complaints
• H/O cough with / without expectoration
• H/O cold,fever
• H/O breathlessness , chest pain , palpitations
• History of recent medical care, medication or allergies
include type of drug, dose & it’s frequency.
2. Surgical history- previous operations, type of anesthesia,
any problem with it. Any family member with anesthesia
3. Allergic history
Eg. – Pt. Having allergy to sulfa drug may have
allergic reaction to thiopentone.
5. 4. History of addiction
Smoking : quantity in packs per day and duration of
Deleterious effects of smoking
i) Vascular disease of peripheral, coronary & cerebral
ii) Chronic bronchitis
iii) Carcinoma of lung, oesophagus, stomach, urinary
-Advised to stop smoking before surgery minimum
about 6 weeks.
6. BENEFICIAL EFFECT OF CESSATION OF SMOKING PRIOR TO
12-24 hours → COHb & Nicotine levels ↓
48-72 hours → COHb normalise & ciliary function improving.
1-2 Wk’s → Sputum production decreases
4-6 Wk’s → PFT’s improve if deranged
6-8 Wk’s → immune fun & drug metabolism normalise
8-12 Wk’s → Overall postop morbidity ↓
b) Alcohol:- Leads to induction of liver enzymes & tolerance to
c) Tobacco use.
5. Menstrual & obstetric history in female patients
7. SYSTEMIC ASSESSMENT
I) CARDIOVASCULAR DISEASES :
Cardiovascular reserve : Ask about maximum distance pt. can
walk, greatest no. of floor can climb without need to stop.
Recent / past myocardial infarction.
Chest pain, chest heaviness, chest tightness.
H/o swelling over ankles.
Shortness of breath.
H/o high BP or medication to prevent high BP.
H/o use of more than one pillow for sleep at night.
8. RESPIRATORY AND AIRWAY PROBLEMS :
-Enquire about upper resp. tract infection – as acute URTI lead to
bronchospasm, laryngospasm, ↑ secretions.
-Adequate mouth opening, loose teeth, dentures
HEPATIC & GI DISEASES
•Hepatic diseases contribute to abnormal clotting &
•GI disease increases risk for aspiration – gastroparesis associated
solid food in stomach & IBD with arthritis in the neck.
•H/o hepatitis,jaundice, liver diseases, malaria
•H/o change in bowel habit
9. BLEEDING PROBLEMS
H/o blood transfusion & its complication.
Family history of serious bleeding problem.
H/o of bleeding from cuts nose bleeds, minor bruises, tooth
extractions or surgery.
H/o convulsion, stroke, paralysis.
H/o numbness, tingling, sensation in arm or leg.
H/o taking antidepressant, anticonvulsant, sedative.
10. MUSCULOSKELETAL DISEASES
H/o Arthritis, low back pain, pain pills.
Produces anaemia, electrolyte disturbances, abnormality in
drug metabolism and excretion.
H/o adequate urine output.
H/o polyuria, polydipsia
H/o recurrent headache, ↑ sweating, flushing of face.
H/o cold / warm in tolerance, muscle cramps in legs to rule out
11. SENSITIVE AREAS
concern with pregnancy & possibility of pregnancy in minor,
haemoglobinopathy, potential for AIDS.
H/o exposure to blood, semen, urine or saliva of any one likely to
High risk groups for AIDS – bi sexual, homosexual, sex with
prostitutes within last 18 yrs.
Detailed examination of CVS, RS & airway is important.
Vital signs noted properly.
- Pulse : Rate, Rhythm, Volume, Peripheral pulse, condition of
vessel wall, presence of collapsing pulse.
- Blood pressure : from both hands with proper size cuff.
- Temperature : Core body temp.
12. Respiratory rate & Pattern.
Jugular venous pressure : Normal 3-4 cm
Elevated – Rt heart failure, tricuspid stenosis, cardiac tamponade
Nails & eyes - Pallor, cyanosis, icterus, clubbing.
State of nutrition : malnourished or obese.
Presence or absence of lymph node enlargement.
• EXAMINATION OF RESPIRATORY SYSTEM
• EXAMINATION OF CARDIOVASCULAR SYSTEM
• EXAMINATION OF ABDOMEN
• EXAMINATION OF CENTRAL NERVOUS SYSTEM
• EXAMINATION OF SPINE- for abnormality or
13. MAJOR CRITERIA
- Paroxysmal nocturnal dyspnea.
- Neck vein distension.
- Basal rales.
- Acute pul oedema.
- S3 gallop.
- JVP increased.
- Hepatojugular reflex.
SIGNS OF CCF
- MINOR CRITERIA
- Ankle oedema.
- night cough.
- exertional dyspnea.
14. EXAMINATION OF AIRWAY :
- Should be done properly to avoid airway obstruction & detect difficult intubation.
- Methods to detect difficult airway
1. Distance between – From inside chin & hyoid bone at least 2 finger breadth.
2. Mallampati Classification :
This is determined by asking the patient to sit in front of anestesiologist and
asking him to open the mouth widely with tongue protruding.
Structures to be visualized
→ Post pharyngeal wall, uvula, faucial piller, soft palate, hard palate
→ Faucial pillers & soft palate, hard palate.
→ Soft palate
→ Only hard palate. (Samson’s Young Modifications)
3. Thyromental Distance : Distance between thyroid notch & tip of jaw.
<6 cm → Difficult Airway.
15. LABORATORY INVESTIGATIONS :
1. Hemoglobin or haematocrit
2. Urine – albumin ,sugar, ketones
3. Blood group
Blood Urea Nitrogen & S. creatinine
Blood Sugar Level Estimation
Coagulation test (PT, PTT)
16. ASA PHYSICAL STATUS CLASSIFICATION
In 1961, ASA adopted physical status classification system of assessing a
pt preopatively, co-relate with periop mortality rate.
→ A normal healthy pt.
→ A pt with mild systemic disease no functional limitation.
→ Moderate to severe systemic disease with some fictional limitation.
→ Severe systemic diseases that is constant threat to life functionally
→ A moribund pt who is not expected to survive 24 hrs with /without surgery.
→ Brain dead for organ harvested
→ If procedure is emergency.
17. PEDIATRIC AIRWAY EVALUATION :
-Pediatric airway differ from adult airway
- Have large head and tongue.
- Narrow nasal passage
- Anterior and Cephald larynx
- Long epiglottis, short trachea & neck.
- Nasal breathers untill abt 5 yrs.
- Cricoid cartilage (Subglottis) narrowest part.
- Chances of accidental extubation more common with head
Note : in pediatric patients H/o immunization.
18. PEROP MEDICATION INSTRUCTION GUIDE LINE –
1.medication to be continued on day of Surgery.
cardiac medication (digoxin)
antidepressant – antianxiety
thyroid, asthma medication
steroids (oral & inhaled)
2. Discontinue 7 days before: aspirin
3. NSAIDS – discontinue 48 hrs before plastic retinal surgery.
4. Oral hypoglycemic drugs discontinue on day of surgery.
5. Insulin – 1/3 dose in morning
6. Warfarin – discontinue 4 days before Sx.
7. Heparin – 4 – 6 hrs before surgery.
8. MAO Inhibitors – 2 weeks before surgery.
19. PREOPERATING FASTING
Risk of Hypoglycemia & dehydration in prolonged fasting.
Should be minimum 4 hrs for clear fluids and milk.
6 hrs for solid food.
To prevent regurgitation and aspiration.
- Obtained from all pt
- Invalid if taken after pre medication
- Of parents or guardian in < 18 yrs & mentally ill pt.
- If parent or guardian not contacted from district medical officer in emergency.
21. AIMS OF PREMEDICATIONAIMS OF PREMEDICATION :
• To allay pre-operative fear and anxiety.
• To produce amnesia and analgesia.
• To reduce secretion from salivary glands and respiratory tract.
• To potentiate anaesthetic drugs
• To depress unwanted reflex vagal activities
• To reduce the pH and volume of gastric contents and risk
associated with regurgitation and aspiration.
• To attenuate sympathetic reflex activities and stress associated
with anaesthesia and surgery.
• To reduce incidence of post operative nausea and vomiting.
22. DrugDrug DoseDose AdvantageAdvantage DisadvatageDisadvatage
0.1 – 0.2 mg/kg IM0.1 – 0.2 mg/kg IM
10 – 15 mg IM in10 – 15 mg IM in
Depression of coughDepression of cough
reflex, miosis,reflex, miosis,
addictive propertiesaddictive properties
FentanylFentanyl 2 – 52 – 5 µµ g/kg IVg/kg IV
Hemodynamics stabilityHemodynamics stability
Absence of histamin releaseAbsence of histamin release
Suppression of stress responseSuppression of stress response
More potent, short durationMore potent, short duration
Muscle rigidityMuscle rigidity
PentazocinePentazocine 0.4 mg/kg IV0.4 mg/kg IV
Less respiratory depressionLess respiratory depression
Low addictive propertyLow addictive property
Sympathetic overSympathetic over
Less sedationLess sedation
1. OPIOIDS1. OPIOIDS :
23. 2. BENZODIAZEPINES
DrugDrug DoseDose AdvantageAdvantage DisadvatageDisadvatage
5-10mg iv5-10mg iv
Potent sedativePotent sedative
Pain on injectionPain on injection
Long actingLong acting
0.03 – 0.050.03 – 0.05
mg/kg IVmg/kg IV
0.5 mg/kg oral.0.5 mg/kg oral.
Short actingShort acting
More potentMore potent
25 – 50 mg oral25 – 50 mg oral
1 – 4 mg IV / IM.1 – 4 mg IV / IM.
Age and liverAge and liver
disease does notdisease does not
affect metabolismaffect metabolism
Long acting.Long acting.
25. A. Antacids
B. H2 antagonists :
• Ranitidine – 50 – 200 mg orally
50 – 100 mg IV
C. Proton Pump Inhibitors:
• Omeprazole – 20 – 40 mg OD
• Lansoprazole – 15 – 30 mg OD
D. Prokinetics :
• Metoclopramide – 0.1 – 0.3 mg /kg IV
• Domperidone– 0.3 – 0.6 mg /kg orally
4. Drugs used to alter gastric fluid volume & pH :
26. 5. ANTIEMETICS
• Nausea and vomiting are single most common factor delaying
recovry of patients.
1. 5HT3 Antagonist-
Ondansetron- 4-8mg iv
0.1mg/kg upto 4 mg in children
• Droperidol 2.5 mg to 10 mg IM or IV.
• Promethazine, perphenazine, promazine.
27. Patients with COPD and Asthma :
• Bronchodilators , steroids should be continued
• Prophylactic antibiotics in COPD patients
• Opioids to be used cautiously – respiratory depression,
• Anticholinergics should be individualized – dries
secretion difficult to remove
• NSAIDS should be avoided
28. Diabetes mellitus:
Avoid hypoglycemia , excessive hyperglycemia ,
Blood glucose should be maintained 120-180m
• OHD to be avoided on day of surgery
• Premedication to avoid aspiration and nausea vomiting
29. PREMEDICATION IN OBSTRETIC
• Patients are at risk of aspiration due to –
Progesterone delays gastric emptying
Drugs esp opioids
• Opioids and BZD may cause adverse effect on neonate
• Amnesia – woman may not be able to remember her
30. PREMEDICATION IN PAEDIATRIC PATIENTS
• Premedication in infants-
•Infant less than 6 months don not require sedative
•Antisialogouges no longer required in neonate
•Premedication in children-
• Aims –
• To get calm and comfortable child in operating room
• To decrease secretions
• To obtund vagal reflexes
• To avoid post op. behavioral disturbances
31. • Considering fear for needles , routes other than im / iv
1.Sedatives and hypnotics-
Midazolam- most commanly used
0.5-0.75mg/kg orally 20 mins prior
0.4-0.5mg/kg per rectally
Trichlophos- 75-100mg/kg orally
Diclofenac- 1.5mg/kg rectally
32. 3. Opioids-
OTFC-in the form of lollypop
4. Ketamine- 6mg/kg orally
5. Anticholinergics - Preffered, along with ketamine
Atropine- 0.02mg/kg im/iv
glycopyrrolate - 4-8ug/kg im/iv