Elements of the Pre-Anaesthetic Evaluation
Determines whether a patient is fit for anaesthesia.
Ensures optimal perioperative outcomes and reduces complications.
Involves assessing patient’s physiological reserve and predicting surgical risk.
Preoperative Testing and Optimisation
Testing must change management; otherwise, it’s unnecessary.
Non-invasive interventions like optimising comorbidities (e.g., anaemia correction, fluid balance).
Cardiology/anaesthesia referrals for complex cases.
ACTIVE Mnemonic for Preoperative Risk Assessment
A – Assess METs and functional status.
C – Cardiac history: Recent MI, heart failure, arrhythmias.
T – Testing: Does additional testing alter management?
I – Infection or inflammation: Active conditions requiring optimisation.
V – Ventilation: Pulmonary disease, CO2 retention, wheezing.
E – Extra considerations: Diabetes, renal disease, anaemia.
Special Considerations in Rural vs. Tertiary Settings
Limited resources in rural areas:
Must balance urgency of surgery vs. stabilisation and transfer.
Importance of knowing local surgical capabilities.
Tertiary hospitals:
More specialised care available (e.g., cardiac catheterisation, ICU support).
Surgical coordination and consideration
Communicating with the Surgical Team
Essential to coordinate management strategies with the surgeon.
Discussions on operative approach based on patient condition.
Example: Lap vs. open surgery considerations based on stability.
Risk Stratification: Classifying Surgeries
Emergency: Immediate intervention (e.g., bleeding from trauma).
Urgent: Needs surgery within 24-48 hours (e.g., hip fracture repair).
Time-sensitive: Within 2 weeks (e.g., cancer resection).
Elective: Can be delayed (e.g., hernia repair).
Low-Risk vs. High-Risk Surgeries
Low-risk:
Cataract surgery, minor dermatological procedures.
Minimal cardiovascular impact, safe under local anaesthesia.
High-risk:
Major abdominal, vascular, or thoracic surgeries.
Require detailed preoperative workup and risk stratification.
Patient Assessment tools
METs assess a patient’s ability to tolerate surgery.
Duke Activity Status Index (DASI) helps determine MET levels.
DASI Overview:
A questionnaire assessing a patient’s ability to perform daily activities.
Scores correlate with METs, allowing stratification of surgical risk.
Can be used as an alternative to formal exercise testing.
DASY Components:
Yard work or other activities
Key thresholds:
1 MET – Basic survival at rest.
4 METs – Walking 5.6 km/h or climbing stairs.
10 METs – Running a short distance, highly functional.
Patients with <4 METs have increased perioperative risk.
Evaluating Cardiopulmonary Reserve
High-risk surgeries (thoracic, liver resection, high-risk TURP) require specialised testing.
Cardiopulmonary exercise testing (CPET) and stress tests provide deeper insights.
Lack of stairs in rural settings – ask function-based questions (e.g., farming activities).
Specific Patient Conditions and Red Flags
Murmurs and Aortic Stenosis
Red flags:
Severe AS: Postpone elective surgery, seek echocardiogram.
Symptomatic AS: High mortality risk.
Mild/moderate AS with good exercise tolerance – may proceed.
ECG Abnormalities & Active Cardiac Conditions
Triphasicular block + syncope: Needs pacemaker before surgery.
Recent myocardial infarction (MI): Consider deferring non-urgent cases.
Low METs and high cardiac risk: Refer for further evaluation.
Pulmonary Considerations
Active wheezing/Asthma/COPD exacerbation:
Postpone elective surgery.
Optimise with bronchodilators, steroids, and antibiotics.
Well-controlled moderate asthma/COPD:
Low risk; proceed with surgery.
Consider spinal anaesthesia if feasible.
Diabetes, Hypertension, and Anaemia Optimisation
Diabetes: Optimise blood glucose.
Hypertension: Control BP within acceptable ranges.
Anaemia:
Consider IV iron or transfusion preoperatively.
Hb optimisation before elective cases.
Decision to Proceed
Decision Algorithm for Proceeding with Surgery
Is the surgery an emergency?
If yes → Proceed with best available resuscitation.
Is there an active cardiac condition?
If yes → Postpone elective, optimise, or refer.
Is the surgery low-risk?
If yes → Proceed without further testing.
Are METs >4?
If no → Consider stress test or optimisation.
Key Mnemonic: ‘Every Anaesthetist Loves Morning Coffee’
E – Emergency or elective?
A – Active cardiac conditions?
C – Cardiology referral/testing if needed.
Perioperative Anaesthetic Management Strategies
Intraoperative monitoring: Arterial lines, cardiac output monitoring.
Blood management: Minimise blood loss, transfuse when necessary.
Analgesia: Multimodal approach (regional + systemic analgesia).
Handling Cancellations and Ethical Considerations
When to cancel a case:
Unoptimised high-risk patients for elective procedures.
Active infection or decompensated medical conditions.
How to handle cancellations:
Communicate effectively with the patient.
Involve referring physicians for further optimisation.
Document reasons for cancellation and plan for reassessment.
Diabetes: Optimise blood glucose.
Hypertension: Control BP within acceptable ranges.
Anaemia:
Consider IV iron or transfusion preoperatively.
Hb optimisation before elective cases.
Decision to Proceed
Decision Algorithm for Proceeding with Surgery
Is the surgery an emergency?
If yes → Proceed with best available resuscitation.
Is there an active cardiac condition?
If yes → Postpone elective, optimise, or refer.
Is the surgery low-risk?
If yes → Proceed without further testing.
Are METs >4?
If no → Consider stress test or optimisation.
Key Mnemonic: ‘Every Anaesthetist Loves Morning Coffee’
E – Emergency or elective?
A – Active cardiac conditions?
C – Cardiology referral/testing if needed.
Perioperative Anaesthetic Management Strategies
Intraoperative monitoring: Arterial lines, cardiac output monitoring.
Blood management: Minimise blood loss, transfuse when necessary.
Analgesia: Multimodal approach (regional + systemic analgesia).
Special Considerations in Rural vs. Tertiary Settings
Limited resources in rural areas:
Must balance urgency of surgery vs. stabilisation and transfer.
Importance of knowing local surgical capabilities.
Tertiary hospitals:
More specialised care available (e.g., cardiac catheterisation, ICU support).
Handling Cancellations and Ethical Considerations
When to cancel a case:
Unoptimised high-risk patients for elective procedures.
Active infection or decompensated medical conditions.
How to handle cancellations:
Communicate effectively with the patient.
Involve referring physicians for further optimisation.
Document reasons for cancellation and plan for reassessment.
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