PRE OPERATIVE ASSESSMENTS

OF PATIENTS
Anthony Nyerges, M.D.
Clinical Professor
Department of Anesthesiology

PRE OPERATIVE ASSESSMENTS

OF PATIENTS
Is the patient in optimum condition for surgery?
Stressors of surgery:
Cardiac
Pulmonary
Endocrine
Neurological
Metabolic

PRE OPERATIVE ASSESSMENTS

OF PATIENTS
AS A CONSULTANT, THE QUESTION
ASKED IS: FOR THIS PATIENT, ARE THE
MEDICAL CONDITIONS AS GOOD AS
THEY CAN BE?

PRE OPERATIVE ASSESSMENTS

OF PATIENTS
Specific recommendations for the situation
at hand:
Hypotension: use Dobutamine infusion
Hypertension: use ACE-I, not a CCB
For post operative ventilation use reverse
I: E mode on ventilator

PRE OPERATIVE ASSESSMENTS

OF PATIENTS
Recommendations such as: Avoid
hypotension, hypoxemia, hypothermia are
not useful.
Recommendations such as Avoid excess
general anesthetics and narcotics are not
useful.

PRE OPERATIVE ASSESSMENTS

OF PATIENTS
Physical examination:
Venous access issues
Arterial access: radial, femoral
Airway / neck for ease of laryngoscopy,
necessity of fiberoptic intubation

PRE OPERATIVE ASSESSMENTS

OF PATIENTS
Chest for vital capacity effort and baseline
breath sounds
Cardiac murmurs, JVD, baseline pressures
Regional anatomy: spine

PRE OPERATIVE ASSESSMENTS

OF PATIENTS
Baseline CBC, Electrolytes, TFT
Baseline CXR (over 50)
Basline EKG (over 40)

PRE OPERATIVE ASSESSMENTS

OF PATIENTS
Specialized cardiac evaluations for compromised
functions:
Ischemia: Dobutamine stress, nuclear perfusion
(myoview), angiography, TEE for SWMAs or
valve dysfunction.

PRE OPERATIVE ASSESSMENTS

OF PATIENTS
Specialized cardiac evaluations for compromised
functions:
Exercise tolerance / intolerance
Current medications and historical use pattern;
anticoagulation issues

PRE OPERATIVE ASSESSMENTS

OF PATIENTS
Specialized pulmonary evaluations:
Resting ABG for obliterative disease
PFTs for specific FEF 25-75, DLCO, lung
volumes for post-anesthetic implications
CXR, CT scanning for pulmonary embolism,
prior resections, effusions

PRE OPERATIVE ASSESSMENTS

OF PATIENTS
Neurological evaluations:
Myogenic dysfunction (post CVA, Hypotonia,
Atrophy, NM junction)
Seizures, LOC, ICP issues

PRE OPERATIVE ASSESSMENTS

OF PATIENTS
Endocrine Dysfunction:
Diabetes: brittle control, Hgb A1C, Hx
Hyperosmolarity, Lactic Acidosis
Thyroid crisis: goiter, thyroid storm, low T3
states
Parathyroid: calcium metabolism on
myocardial function, NMJ function

PRE OPERATIVE ASSESSMENTS

OF PATIENTS
Endocrine Dysfunction:
Adrenal: Use of intraoperative steroids and
wound healing, Hyperglycemia
Special TPN Issues: Hepatic clearances and
myogenic functionality

PRE OPERATIVE ASSESSMENTS

OF PATIENTS
Low concentrations of potent inhaled vapors
decrease reflexes, diaphragmatic activity
NM antagonists increase nicotinic tone
Sympathetic / parasympathetic reset BP
control, peristalsis, temperature

PRE OPERATIVE ASSESSMENTS

OF PATIENTS
Opiate effects on sedation, cough reflex,
sympathetic control
LMWH effects on post regional anesthesia

PRE OPERATIVE ASSESSMENTS

OF PATIENTS
33 y.o. male C5 quadriplegia x10 years, OSA
syndrome, Hx Ileal conduit, wheelchair
dependent
Revision of tracheostomy in past
Hx of sweating post prandial

PRE OPERATIVE ASSESSMENTS

OF PATIENTS
Scheduled for new Ileal conduit diversion
Anesthesia: Choice

PRE OPERATIVE ASSESSMENTS

OF PATIENTS
No PFTs performed
No ABG performed
No evaluation of autonomic dysreflexia
No thyroid functions
No airway exam

PRE OPERATIVE ASSESSMENTS

OF PATIENTS
Fiberoptic emergency intubation
Hyper / hypotensive crises
Femoral arterial access
Unanticipated ICU stay, 3-day intubation,
postoperative pulmonary and cardiology
consultations

PRE OPERATIVE ASSESSMENTS

OF PATIENTS
86 y.o. male with mechanical fall: femoral neck fracture
VIP status
Hx or myocardial infarction s/p stents (3 years ago)
Hx of A-Fib in past
Hx diastolic dysfunction of TTE study
Anticoagulated on coumadin

PRE OPERATIVE ASSESSMENTS

OF PATIENTS
#1 ECG in EMC yields 1 AVB
#2 ECG 1 hour later yields new LBBB
HCT = 32, but dehydrated!
Mild dyspnea on prior walking
Surgery wishes to proceed urgently

PRE OPERATIVE ASSESSMENTS

OF PATIENTS
No regional technique possible
Awake arterial line
Central venous cordis sheath
Transfusion 4 units PRBC
Post operative mechanical ventilation (Dynamic
Compliance Poor)

PRE OPERATIVE ASSESSMENTS OF PATIENTS

Case Scenario
29 y.o. male history of aplastic anemia ANC 0.1 on GMCSF
followed by hematology oncology awaiting BMTx (XRTx +
chemo preconditioning). Now with fibrous cyst of tongue
with exfoliation scheduled for hemiglossectomy. Arrives in
PTU for surgery:
No information from Hem-Onc
Case delayed
Post operative wound care
Reverse isolation environment

PRE OPERATIVE ASSESSMENTS OF PATIENTS

Case Scenario (cont.)
29 y.o. male history of aplastic anemia ANC 0.1 on GMCSF
followed by hematology oncology awaiting BMTx (XRTx +
chemo preconditioning). Now with fibrous cyst of tongue
with exfoliation scheduled for hemiglossectomy. Arrives in
PTU for surgery:
Antibiotic, antiviral, antifungal prophylaxis
Use of nitrous oxide
Postoperative bone pain issue-GMCSF vs. operative site
Immune effects of opiates

PRE OPERATIVE ASSESSMENTS

OF PATIENTS
63 y.o. Psychologist C1 C2 fracture
Admitted 2 weeks
Acute delirium unknown cause
Chronic alcoholism
Hyponatremia, anemia, cachexia
? R Lobar infiltrate

PRE OPERATIVE ASSESSMENTS

OF PATIENTS
No cranial imaging studies
No workup of hyponatremia
Intraoperative fiberoptic intubation
Intraoperative bronchoscopy
Post operative mechanical ventilation
Recommend CSF puncture and workup