PAC

Risk Minimization and Patient

optimization
Starting new drug treatments:
B-blockers in certain subgroup of cardiac patients
Bronchodilators in respiratory patients
Vitamin K for patients with deranged coagulation
Postponing the surgery till patient’s condition improves
Advising to u
• Optimization of the patient’s presenting
disease and of co-morbid conditions
• Done by ourselves or in consultation with
other departments
• Example:
– Optimization of drug treatment
• Increasing/decreasing dose of thyroid medications or
antihypertensive drug therapy
– Stopping specific drugs before the surgery
• Stopping anti-platelets or anticoagulants 5-7 days
before surgery in certain conditions
– ndergo surgery/interventions to reduce risk:
• Aortic valve replacement in patient with severe
symptomatic aortic stenosis in a patient scheduled for
elective knee surgery
 Outline
• PAC-Introduction
• ASA Grading
• METS
• BMI
• NPO Guidelines
• Airway Assessment
– Starting new drug treatments:
• B-blockers in certain subgroup of cardiac patients
• Bronchodilators in respiratory patients
• Vitamin K for patients with deranged coagulation
– Postponing the surgery till patient’s condition improves
– Advising to u
 Introduction: Preoperative assessment

• All patients planned for surgery must undergo

preoperative evaluation
• The principle aims of PAC are to:
1. Assess perioperative risk,
2. Optimise the primary and co-morbid condition
3. Minimize that risk further by producing a tailored and
individualized anesthesia plan,
4. Educate the patient about the process, choices and
expectations
5. Informed consent.
ASSESSMENT OF PREOPERATIVE
RISK
 History
• Planned procedure,
• Presenting illness,
• Comorbid conditions (pre-existing diseases and new Ds),
• Detailed review of organ systems,
• Past anesthetic history with review of complications,
• Assessment of allergies and medications,
• Documentation of substance use or abuse, and
• The last oral intake(NPO).
• If any abnormlity/disease is found:
– Severity of disease,
– efficacy of treatment, and
– impact on daily function
• Always check all previous medical and Anesthesia records
 Examination
• General physical examination, including
– in respiratory patients
• Vitamin K for patients with deranged coagulation
– Postponing the surgery till patient’s condition
improves
– Advising to uExamination of organ systems, esp. which
were found abnormal in History.
• Airway Examination: In ALL Patients
• Spine/Back especially if spinal/epidural
anaesthesia is planned
– Site of injection in cases of regional anesthesia
 Investigations
• Standard Guidelines state that:
Investigations are indicated for evaluating existing
medical conditions or for disease diagnosis only when
an abnormal result will have an impact on
management of the patient or direct further testing
• Routine investigations are not indicated
• Our institute recommends only following
routine investigations for all patients:
– Hemogram
– Viral markers for HIV, Hepatitis B &C
– Weight, Height and BMI
– Starting new drug treatments:
• B-blockers in certain subgroup of cardiac patients
• Bronchodilators